Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
August 2, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acupuncture services are not payable as 
they were not rendered on the basis of a covered diagnosis.  
 
 
 
  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Specifically, the acupuncture services in this case 
were not rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan 
does not have to pay for the acupuncture treatments (97810, 97811) provided on August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100), x-ray exam 
of the thoracolumbar junction spine (72080), office visit (99205), and the x-ray exam of the cervical spine 
(72040) provided on August 16, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit by 
Medicare or the Plan.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100), x-ray exam of the 
thoracolumbar junction spine (72080), office visit (99205), and the x-ray exam of the cervical spine (72040) 
provided on August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the requested inserts are medically necessary for 
the enrollee's medical condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that the enrollee does not suffer from diabetic foot disease, and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for the enrollees condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics and retainer crowns (D6245, D6740) provided on 
July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 pay for pontics 
and retainer crowns (D6245, D6740) provided on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240).  
 
You asked the Plan to pre-approve a shower chair. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), and intraoral  comprehensive series of radiographic images (D0210) provided on August 4, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were not made aware of the change to the 
agreement contract. The Plan denied your request. The Plan says your benefit for the requested services has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service March 23, 2023. 
The intraoral  comprehensive series of radiographic images was exhausted on September 14, 2022. You 
received a panoramic radiographic image (D0330) under claim number ending in 28281. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), 
and intraoral  comprehensive series of radiographic images (D0210) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on August 11, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you were going through the book and found 
the section on hearing aids that said the Plan covers up to $500 for hearing aids. You also say nothing is said 
about getting an approval from the Plan first, to read further, or to go on the internet. The Plan denied your 
request. The Plan says hearing aids must be purchased through the Plan hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are purchased through the Plan hearing.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5261) provided on August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #5. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
charges for any type of implant and all related services are not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test (D0431) provided on March 3, 
2023. 
 
You asked the Plan to pay for adjunctive pre-diagnostic test. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 pay for 
adjunctive pre-diagnostic test (D0431) provided on March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on August 29, 2022, and
billed under code 43659.

You asked the Plan to pay for code 43659 and 43281. The Plan says while code 43281 was paid, code 43659 is
not supported by the records provided. Maximus overturned the Plans denial for insufficient explanation in the
case file. The Plan requested a reopen and demonstrated that claim was billed with codes 43659 for Unlisted
laparoscopy procedure, stomach, and code 43281-AS for -Laparoscopy, surgical, repair of paraoesophageal
hernia, includes fundoplasty, when performed, without implantation of mesh, Physician assistant, nurse
practitioner, or clinical nurse specialist services for assistant at surgery. The operative report documented the
rendering provider (Box 32) a PA-C, stating the provider assisted with the paraoesophageal hernia repair
(43281) billed modifier -AS.

This code was paid as documented on the Provider Remittance Advice. However, the unlisted code (43659)
was billed with a line comment "Laparoscopic Gastric Perforation Repair". The operative report does not
document any gastric perforation or repair of a gastric perforation. The denied code, 43659 for Unlisted
laparoscopy procedure, stomach was billed without an -AS modifier. There is no documentation that the
provider listed performed any surgical procedure as the primary surgeon. The providers role as an assistant
would require billing with the AS modifier. Therefore, the claim could not be paid as billed.

The Plan is correct in this case. 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. The records submitted do not show the billing
provider performed or assisted with or was the primary physician for code 43659. The claim was not billed
with the AS modifier if applicable for this code. Medicare rules for coverage of code 43659 have not been met.
Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on August 29,
2022, and billed under codes 43281 and 43659.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial upper denture (D5225) provided on August 15, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you went to the provider in February for a new 
dental bridge and in August you went to have a new dental bridge placed. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 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, certain limitations apply. The record 
shows the Plan paid for a partial upper denture (D5221) on March 8, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 8, 2023. Therefore, we decided that 
the Plan does not have to pay for a partial upper denture (D5225) provided on August 15, 2023.  
 
Your complaint about the providers charges for dental services provided is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
10, 2022. 
 
You asked the Plan to pay for the ED services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on July 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET with CT scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. The Plan denied your request. The Plan says a 
PET scan with CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan with CT scan. Our reviewer 
says that a PET scan with CT scan is not medically necessary. Our physician reviewer found the records shows 
that the enrollee has right hip pain and was diagnosed with focal tear of right gluteus maximus near 
trochanteric insertion and tendinosis of gluteus medius muscle. Furthermore, it is unclear as to why the PET 
scan with CT scan was ordered with the provided medical records. 
 
  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 PET scan with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET with CT scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0300) billed for date of services 
from May 5, 2023, to May 9, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported with an incorrect revenue code. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services (G0300) billed for date of services from May 5, 2023, to May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 26, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was not filed on time due to 
waiting on the enrollee to sign the consent form. The Plan denied your request. The Plan says the claim has 
exceeded the time limit for filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until September 26, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on September 21, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that the enrollee was unable to see an 
in-network provider or request an authorization before the services were rendered. 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 subsequent nursing 
facility care. provided on September 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90471 and 90715 billed for date of service 
March 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are payable under Medicare 
guidelines. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that code 90471 has a status indicator of Q1. This service is packaged into payment for services with a 
status indicator of V, such as billed code 99283. We find that code 90715 has a status indicator of N. This 
service is packaged into payment for a separately paid service. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 90471 and 90715 billed for date of service March 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on April 26, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the transport method was medically 
necessary. The Plan denied your request. The Plan says treatment was available at the initial facility. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found transfer was undertaken due to 
patient preference. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for durable medical equipment (DME) and a 
specialist office visit provided on July 27, 2023. 
 
You asked the Plan to waive the cost share for DME and a specialist office visit. You say that you disagree 
with the cost share. 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 durable medical equipment (DME) and a $20 copayment for physician/practitioner services/ 
specialist.  
 You have been asked to pay a 20% coinsurance for DME and a $20 copayment for a specialist office visit. The 
total allowed amount for the DME is $41.62. You are being asked to pay $8.32 ($41.62 x 20% = $8.32). The 
total amount you owe is $28.32 ($20 + $8.32 = $28.32). This item/service falls within the durable medical 
equipment (DME) and physician/practitioner services/specialist 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 cost share for durable medical equipment (DME) and a specialist office visit provided on July 27, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on June 17, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you do not feel 
that you should have to pay the emergency department bill. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $75 copayment for each emergency care visit.  
 
The enrollee has been asked to pay a $75 copayment for the emergency care visit. This item/service falls within 
the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency department visit provided on June 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on July 17, 
2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary due to the enrollee's non-healed fractures, oxygen administration and bed confinement status 
requiring a medical attendant.  The Plan denied your request. The Plan says transport to a doctors office is not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the non-emergent transport services provided on 
July 17, 2023.