Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 16, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610), a frenulectomy 
(D7960), an alveoloplasty in conjunction with extractions (D7310), anesthesia (D9222/D9223), and panoramic 
radiographic imaging (D0330). 
 
You asked the Plan to pre-approve the dental services. You say that this dental work was all medically 
necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0330 was exhausted on date of service June 8, 2023. D9610, D7960, D7310, D9222, 
or D9223 are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic parenteral drug (D9610), a frenulectomy (D7960), an alveoloplasty in conjunction with extractions 
(D7310), anesthesia (D9222/D9223), and panoramic radiographic imaging (D0330).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 24, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming of dystrophic nails provided on September 20, 
2023. 
 
You asked the Plan to pay for trimming of dystrophic nails. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for trimming of dystrophic 
nails provided on September 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided August 2, 2023, through 
August 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99213 is the office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer found there are no medical 
records to support 99213. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) provided August 2, 2023, through August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed height hospital bed (E0250). 
 
You asked the Plan to pre-approve a fixed height hospital bed. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a fixed height hospital bed. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you do not have a 
condition requiring positioning not feasible with a standard bed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a fixed height hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a fixed height hospital bed (E0250).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 4Kscore test provided on June 12, 2023. 
 
You asked the Plan to pay for the 4Kscore test. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this test was not medically necessary due to lack of medication documentation 
supporting the indication of performing the test. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the 4Kscore test have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the 4Kscore test provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by codes 
99233 billed for dates of service July 4, 2023, and July 6, 2023, 99232 billed for date of service July 7, 2023, 
and 99233 billed for date of service July 8, 2023. 
 
You asked the Plan to pay for the evaluation and management services. You say that the evaluation and 
management services should be paid as billed because they are supported in the documentation and the diagnoses reported are payable. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F30.9 has an Excludes1 note in relation to F31.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the evaluation and management services have not been met. Therefore, we decided that the Plan does 
not have to pay for the evaluation and management services described by codes 99233 billed for dates of 
service July 4, 2023, and July 6, 2023, 99232 billed for date of service July 7, 2023, and 99233 billed for date 
of service July 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 07, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on November 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement
(D6058) and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve custom fabricated abutments - includes placement and abutment supported
porcelain/ceramic crowns. You say that you submitted an appeal letter that indicates you had approval for the
service in 2022. The Plan denied your request. The Plan says your benefit for the requested item or service has
already been exhausted. Maximus overturned the Plan's denial based on a lack of information. The Plan
requested a reopening and stated that this service is not covered because your benefit has been exhausted. The
Plan is correct in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, certain
limitations apply. The record shows your benefit for implants was exhausted on date of service January 31,
2023. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment - includes
placement (D6058) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed with code 
A4239 for date of service July 11, 2023. 
 
You asked the Plan to pay for the continuous glucose monitor supplies. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the supplies rendered exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that the supply allowance (code A4238 or A4239) is 
a monthly allowance that may be billed up to a maximum of three (3) units of service (UOS) per ninety (90) 
days at a time. Billing more than three (3) UOS per ninety (90) days of code A4238 or A4239 will be denied as 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that one month of supplies was billed on 
June 21, 2023, by a different provider. This overlaps the current order and does not support a one-month supply 
billed on July 11, 2023. The provider reported supply allowance for therapeutic continuous glucose monitor 
supplies with HCPCS code A4239 which includes all supplies and accessories for a 1-month supply before the 
expiration of a previously reported supply period, which does not follow industry standard coding rules. 
Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor supplies billed with code A4239 for date of service July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diabetic supplies provided on June 27, 
2023, to September 27, 2023. 
 
You asked the Plan to waive the copayment for the diabetic supplies. You say that you were advised the insulin 
supplies and pump would be covered 100% by your insurance. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered durable medical equipment item. 
  You have been asked to pay a total of $342.53 for the diabetic supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 27, 2023 Diabetic supplies $456.70  20% $91.34 
July 27, 2023 Diabetic supplies $456.70  20% $91.34 
August 27, 2023 Diabetic supplies $456.70  20% $91.34 
September 27, 2023 Diabetic supplies $342.53 20% $68.51 
TOTAL:    $342.53 
 
These items/services fall within the durable medical equipment (DME) and related supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the diabetic supplies provided on June 27, 2023, to 
September 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220) and pulp 
vitality tests (D0460) provided on March 13, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the first intraoral periapical x-ray and pulp vitality tests. You say that you 
are requesting a formal dispute of your dental claim for March 13, 2023. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220) 
and pulp vitality tests (D0460) provided on March 13, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous, osteoperiosteal, or cartilage graft of the 
mandible or maxilla (D7950). 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection, and this procedure is 
necessary. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T1019 billed for date of service July 8, 2023, 
to July 14, 2023. 
 
You asked the Plan to pay for procedure code T1019. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code T1019 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code T1019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T1019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T1019 billed for date of service July 8, 2023, to July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on
March 25, 2023.

You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that your primary care
provider said you would only pay around $500 for this service. The Plan denied your request. The Plan says
this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening
and stated that Maximus did not apply the correct criteria. The Plan is correct in this case. The Plan has now
submitted a copy of the correct 2023 EOC with the reopening request. The rules say a plan must disclose to its
enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and
coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable
medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the
osteogenesis stimulator. This item/service falls within the Durable medical equipment (DME) and related
supplies benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the osteogenesis
stimulator provided on March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751) for teeth #22, #23, #26, and 
#27, and pontics (D6241) for teeth #24 and #25. 
 
You asked the Plan to pre-approve D6751 and D6241. You say that you would prefer a fixed bridge. The Plan 
denied your request. The Plan says the requested dental services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D6751 and 
D6241 when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve D6751 and D6241. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found dental bridges are not placed on 
teeth with a guarded to poor long-term prognosis as they will fail soon after placement and may exacerbate the 
amount loss around the teeth holding onto the bridge. More information is required to determine whether a 
bridge to replace the lower teeth are medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of D6751 and D6241 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6751) for teeth #22, #23, #26, and #27, and pontics (D6241) for 
teeth #24 and #25.