Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical dental implant. 
 
You asked the Plan to pre-approve these services. You say that you are unable to chew properly. The Plan 
denied your request. The Plan says you have exhausted the benefit allowance. 
 
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. The Plan covers up to $250 for 
comprehensive dental services per quarter. 
 
We looked at the file and Medicare rules. The file shows that you have used the full $250 allowance for 
comprehensive dental services for this quarter. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a surgical dental implant.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) requested on 
November 24, 2020. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from additional 
daily skilled care. The Plan denied your request. The Plan says that the requested stay cannot be approved since 
it is not medically necessary and there has not been a three-day inpatient hospital stay prior to the request. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide medical records that are contemporaneous to the 
requested admission. The original case file did not include any medical records. Maximus requested that 
medical records from the recent hospital visit be submitted. The records provided were from the SNF stay from 
November 13, 2020 to about November 18, 2020, several days before the hospital stay. From these records, a 
determination on the necessity of SNF care starting on November 24, 2020 cannot be made. Therefore, we 
decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) requested on November 
24, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says you have exhausted your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per calendar year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that this physical therapy would be beneficial for 
the enrollee. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because there is no evidence to support the medical necessity of additional physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy and it does not appear 
that the enrollee's current functional level requires the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist or 
under the supervision of a therapist. The staff has been given recommendations for appropriate level of care for 
safety. The specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, 
design, and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin three surface-anterio (D2332) and provisional splint 
extracoro (D4321) provided on April 9, 2020. 
 
You asked the Plan to pay for resin three surface-anterio and provisional splint extracoro. You say that the 
service was medically necessary. The Plan denied your request. The Plan says your plan does not cover the 
dental procedures and therefore the procedure will not be approved or reimbursed. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for resin three surface-anterio 
(D2332) and provisional splint extracoro (D4321) provided on April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified maxillofacial prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 an 
unspecified maxillofacial prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement and three preventive procedures 
provided from June 17, 2020, to June 25, 2020. 
 
You asked the Plan to pay for the full mouth debridement and preventive procedures. You say that a Plan 
representative assured you that you were covered 100%. The Plan denied your request. The Plan says these 
services are not covered. 
 
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 full 
mouth debridement and three preventive procedures provided from June 17, 2020, to June 25, 2020.  
 
Your complaint about possibly being misinformed by the Plan 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral exam to evaluate a problem (D0140) provided 
on July 27, 2020. 
 
You asked the Plan to pay for a limited oral exam to evaluate a problem. You say that the service was 
medically necessary. The Plan denied your request. The Plan says you have exceeded the frequency limitation 
of this service. 
 
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. This benefit includes one 
limited exam to evaluate a problem (D0140) per plan year. 
 
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. Specifically, you have exceeded the frequency limitation for this 
benefit. Therefore, we decided that the Plan does not have to pay for a limited oral exam to evaluate a problem 
(D0140) provided on July 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on May 15, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you did not request prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the duplex scan provided on May 15, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient diagnostic and outpatient procedure services 
provided to the enrollee on April 9, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the timeframe in which the Plan had to make its decision expired. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that outpatient diagnostic and outpatient procedure services require prior authorization. The records provided 
do not show the enrollee had prior authorization for the services provided. Therefore, we decided that the Plan 
does not have to pay for outpatient diagnostic and outpatient procedure services provided to the enrollee on 
April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutments fused to a porcelain crown 
(D6057, D6059) provided on February 4, 2020. 
 
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 under 
your contractual policy or by Medicare. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom 
fabricated abutments fused to a porcelain crown (D6057, D6059) provided on February 4, 2020.  
 
Your complaint that you received inaccurate coverage information from several Plan representatives 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for injection procedure for radiopharmaceutical localization by 
non-imaging probe study (78808) provided February 24, 2020. 
 
You asked the Plan to pay for the diagnostic procedure. You say that the service was billed with a valid place 
of service as outpatient. Attached is the medical records as proof of service and prove medical necessity. The 
Plan denied your request. The Plan says place of service inappropriate for procedure per Medicare guideline. 
 
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 78808 is  Injection procedure for radiopharmaceutical 
localization by non-imaging probe study, intravenous (eg, parathyroid adenoma), to describe minimally 
invasive radioguided parathyroidectomy. 
 
We find that CPT code 78808 is not supported in the medical record. Specifically, CPT code 78808 has a 
PC/TC indicator of 5 as found on the PFS Relative Value Files on CMS.gov. This indicator identifies codes 
that describe a service incident to physician services for which payment may not be made when they are 
provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be 
used with these codes. Based on this information, we decided that Medicare rules for coverage of the diagnostic 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for injection procedure 
for radiopharmaceutical localization by non-imaging probe study (78808) provided February 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 14 additional physical therapy sessions coded as 
97112, 97116, 97110 and 97140. 
 
You asked the Plan to pre-approve the additional physical therapy sessions. You say that the medical records 
provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the 
initial request from the LTC facility for 20 PT sessions. Six PT sessions were approved. There was no 
documentation that the approved therapy was provided. The approved sessions should be provided. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 the additional physical therapy sessions. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the documentation doesn't support that the enrollee 
 
 
requires further outpatient physical therapy sessions. The health plan has approved 6 sessions to treat the 
reported decline in function. She appears to be at or near her baseline functional status and it is unclear if she 
has already had the originally authorized physical therapy sessions. The requested physical therapy is not 
medically necessary. 
 
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 additional physical therapy sessions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the 14 additional physical therapy sessions coded as 97112, 
97116, 97110 and 97140.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of skilled need. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. The documentation doesn't support that 
you are home bound or that you require any skilled services therefore home health aide services are not 
medically necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on September 27, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was ordered by telemedicine which is a 
Medicare-prohibited action, this testing is not covered for screening purposes, and the documentation submitted does not 
support the Place of Service (POS) code billed on this claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed 
above, are not covered. 
 
The tests at issue in this appeal were requested for screening purposes. Medicare does not cover these tests for screening 
purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on September 
27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on December 30, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these tests were ordered by 
telemedicine which is a Medicare-prohibited action and these tests are not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal were requested for screening purposes. Medicare does not cover these tests for 
screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing 
provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 6, 2020. 
 
You asked the Plan to pay for hearing aids. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the hearing benefit is not covered if the services are not registered in advance. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when you contact and order through the Plan's hearing department in advance.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aids have not been met. Specifically, you did not contact the Plan for 
the hearing aids. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 6, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 73502, CPT 73560) provided on June 8, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 73502 is "Radiologic examination, hip, unilateral, with 
pelvis when performed; 2-3 views". The CPT Code Manual definition of code 73560 is "Radiologic 
examination, knee; 1 or 2 views". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT codes 73502 and 73560 is not supported by the records provided. Our coding reviewer found that while 
x-rays were taken in the office, the only images described as having been performed are bilateral standing knee 
x-rays and a pelvis x-ray. Additional knee images and hip images are not noted. As such, the billing of CPT 
73502, which requires hip imaging, and CPT 73560, which requires additional knee views, is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 73502, CPT 73560) provided on June 8, 2020.