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

 
We decided that the Plan does not have to pay for procedure code J8499 provided from December 10, 2022, to 
December 12, 2022. 
 
You asked the Plan to pay for procedure code J8499. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 looked at the file and Medicare rules. In this case, code J8499 has a Payment Status Indicator of E1 
indicating that it is not paid by Medicare when submitted on outpatient claims. Therefore, we decided that the 
Plan does not have to pay for procedure code J8499 provided from December 10, 2022, to December 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0028 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code S0028. You say that you disagree with the denial. 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 S0028 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0028 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0028 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0028 billed for date of service June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260) and the placement of intra-
socket dressing (D7922) provided on September 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were necessary because of 
the extractions. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the osseous surgery and the placement of intra-socket dressing 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 Plan's 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 the 
osseous surgery (D4260) and the placement of intra-socket dressing (D7922) provided on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921), local 
anesthesia in conjunction with operative or surgical procedures (D9215). 
 
 You asked the Plan to pre-approve the gingival irrigation and local anesthesia. You say that you are requesting 
a reconsideration as you are scheduled for a root canal. You also say that your cost will be about $2600.00. The 
Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
gingival irrigation  per quadrant (D4921), local anesthesia in conjunction with operative or surgical 
procedures (D9215).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for home health services billed to the enrollee for May 30, 2022, to June 28, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that per Medicare Claims Processing Manual, Chapter 10, Section 10.1.10.3 - Submission of the Notice of Admission (NOA), home health agencies (HHAs) no longer submit Requests for Anticipated Payment (RAPS -TOB 0322) for any HH period of care with a from date on or after January 1, 2022. Instead, for each admission to home health, the HHA notifies Medicare systems via submission of an NOA. 

Per Medicare Claims Processing Manual, Chapter 10, Section 40.2 - HH PPS Claims: The following data elements are required to submit a claim under home health PPS. For billing of home health claims not under an HH plan of care (not under HH PPS), see 90. Home health services under a plan of care are paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit one claim for each 30-day period of care. Claims submitted before an NOA has been received for the beneficiary will be returned to the provider. In the provider's appeal, they advised they sent a RAP on April 1, 2022. A review of our systems shows that there were no RAPs or NOAs received from the provider for any series of care in 2022. According to the PPS claims submitted, the admission date for the HH series began on March 31, 2022. The Plan never received a NOA from the provider for this series of home health care episodes. Per the
above Medicare guidelines, the provider is required to send a NOA at the beginning of any admission to
Home Healthcare that begins on or after January 1, 2022. As the provider never sent a NOA, the Plan
has correctly denied the claim for payment.

The Plan is correct in this case The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the omission of the required NOA documentation. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services billed to the enrollee for May 30, 2022, to June 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
December 02, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for an emergency care visit. This item/service falls within the 
Emergency care 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 an emergency care 
visit provided on December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 13, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain authorization. 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 domiciliary or rest home 
visit provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the progressive lenses (V2781) provided on January 
11, 2023. 
 
You asked the Plan to pay more for the progressive lenses. You say that since getting these new glasses you 
have had very little trouble with your eyes, a real success story. You also say that because of this positive 
outcome you should get the allowed coverage afforded to you. The Plan denied your request. The Plan says 
your allowance has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $350 allowance every calendar year that you can use to pay for eyewear. 
 
 
 We looked at the file and the Plan's rules. The record shows that your $350 eyewear allowance was exhausted 
on this purchase on date of service January 11, 2023. Based on this information, we decided that the Plan's 
rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not 
have to pay more for the progressive lenses (V2781) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on February 22, 2023. 
 
You asked the Plan to pay for a home or residence visit. You say that these services are 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 a home or residence visit 
provided on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 05, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on January 05, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
disagree with the denial and would like the plan to reconsider payment. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 18, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on January 17, 2023. 
 
You asked the Plan to pay for home evaluation visit. You say that it is the responsibility of the facility to obtain 
authorization. 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 home evaluation visit 
provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2022, to November 
03, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 September 22, 2022, to November 03, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 31, 2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for no medical records. The Plan requested a reopen and provided additional information to show medical records were requested several times that support the claim however those records were not submitted.

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. 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 these services have been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on 
September 28, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. 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 visits provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share ($362.88 ($181.44 x2) and $15) for the capsaicin and the podiatry office visit provided on January 9, 2023.
You asked the Plan to waive this cost share. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus reopened the appeal to explain all three copayments listed in the case file.
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 10% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $15 copayment for each Medicare-covered podiatry visit.
You have been asked to pay $362.88 ($181.44 x2) which is 10% coinsurance of the allowed amount for the capsaicin patch. You have also been asked to pay a $15 copayment for the podiatry office visit. 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 capsaicin and the podiatry office visit provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on January 17, 2023. 
 
You asked the Plan to pay for outpatient surgery services. You say that the records attached support the 
services provided. 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 outpatient surgery 
services provided on January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the allograft, morselized, or placement of 
osteopromotive material, for spine surgery (Medtronic infuse bone morphogenetic protein) (20930). 
 
You asked the Plan to pre-approve Medtronic infuse bone morphogenetic protein. You say that the surgery is in 
7 days and the enrollee needs everything covered in order to be able to get this surgery taken care of. The Plan denied your request. The Plan says this service is experimental and investigational because the recombinant 
BMP is not FDA approved for posterior lumbar fusion. There are not enough studies in safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
allograft, morselized, or placement of osteopromotive material, for spine surgery (Medtronic infuse bone 
morphogenetic protein) (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 19, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on January 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 billed for date of service January 25, 
2021.  

You asked the Plan to pay for procedure code 95908. You say that this claim should be reprocessed due to 
timely filing waivers in effect. The Plan denied your request. The Plan says payment for code 95908 is bundled 
into payment for code 95861. 
 
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, we have confirmed that code 95908 
is a column II code to column I code 95861 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95908 billed for date of service January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the records attached support the 
services provided. 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 
copayment for outpatient diagnostic test and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an office visit. This item/service falls within the outpatient 
diagnostic test and therapeutic services and 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 an office visit provided on March 22, 2022.