Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care billed to the enrollee for October 25, 2020.
You asked the Plan to pay for inpatient services. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan denied your request. The Plan says that Medicare coverage criteria are not met.
We overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan states that the enrollee left the hospital from the emergency room on their own accord. The enrollee
presented to the emergency room at 6:31 am and left against medical advice at 11:52 am. The records show the
request for a bed was cancelled.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, inpatient
services were not provided to the enrollee. Medicare billing criteria were not met. Therefore, we decided that
the Plan does not have to pay for inpatient care billed to the enrollee for October 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided October 8, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you thought you would be covered for the x-
rays with no expense. The Plan denied your request. The Plan says these services are not covered under your 
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 the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with limited field of view  less than one whole jaw (D0380) provided November 16, 2021. 
 
You asked the Plan to pay for the cone beam CT scan. You say that this type of image was medically 
necessary. The Plan denied your request. The Plan says this service is not covered under your 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 the cone 
beam computed tomography (CT) image capture with limited field of view  less than one whole jaw (D0380) 
provided November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
provided on October 5, 2020. 
 
You asked the Plan to pay for the prefabricated post and core. You say that you financially need help paying 
this bill. The Plan denied your request. The Plan says this claim was received after timely filing limitations. 
 
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 prefabricated post and core was not filed until December 30, 2021. 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 prefabricated post and core in addition to 
crown (D2954) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the payment 
is bundled into other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is 
subsumed by the payment for the services to which they are incident. 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 the anesthesia services provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry (eg, 
MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or 
quantitative, each specimen (CPT code 83789-59) provided on July 23, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported. 
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 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 service. Our reviewer found documentation submitted 
was reviewed and does not meet criteria. Documentation supports validity testing for drug testing was 
performed.  Per CMS, this procedure is not separately reported. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, 
QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT code 
83789-59) provided on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 27, 2021
and billed under code 30901-50.
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 Medicare billing criteria are not met. We overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional information. The
Plan stated that Current Procedural Terminology (CPT) code 30901-50 (1 unit) remains not supported.
The documentation submitted did not include documentation of Control nasal hemorrhage, anterior, simple
(limited cautery and/or packing) any method was performed bilaterally; therefore, the billed service cannot be
verified. Of note the submitted documentation indicates the service was performed only in the left side. It is
noted that multiple attempts were made to contact the provider for additional information. Per Medicare rules, a
code may be reported only if all services described by that code have been performed. Insufficient
documentation was submitted to the Plan to corroborate the services billed. In addition, the documentation
submitted by the provider on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, code 30901 cannot be paid as billed as
insufficient medical records were submitted to support the services billed. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services
provided to the enrollee on July 27, 2021 and billed under code 30901-50.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for full replacement of a continuous positive
airway pressure (CPAP) device (E0601) device.

You asked the Plan to provide coverage for a new CPAP device. You say that your current device was recalled,
and the Plan should pay for a new one. The Plan denied your request. The Plan says your current device was
recalled but has not been shown to be inoperable nor has it been determined it cannot be repaired. There is no
indication the provider cannot set you up with loaned equipment while yours is looked at for the recall.
We overturned the Plans denial. The Plan requested a reopen and stated Maximus applied the incorrect
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say equipment less than five
years old would be repaired but not fully replaced unless it is completely inoperable.

Your current equipment is four years old. You requested a new machine due to a provider recall. However,
there is no indication that your current equipment was not working or that you were not being provided loaner
equipment by the provider or warrantor while yours was being repaired due to the recall. The Plan is only
required to intercede and pay for replacement equipment from another provider when the current equipment
provider is not able to loan you equipment or fix your current equipment within a reasonable amount of time.
This has not been shown to be the issue in this case. Therefore, we decided that the Plan does not have to
provide coverage for full replacement of a continuous positive airway pressure (CPAP) device (E0601) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the core buildup, including any pins 
when required (D2950), crown - porcelain fused to high noble metal (D2750), resin-based composite - two 
surfaces, posterior (D2392), and resin-based composite - one surface, posterior (D2391) provided March 18, 
2021. 
 
You asked the Plan to provide additional payment for the core buildup, crown and fillings. You say that these 
services were vital, and the insurance plan did not inform you they would not be covered. The Plan denied your 
request. The Plan says the core buildup and crown are not covered under your benefits. You have reached you 
annual dental maximum and therefore no further payment is due for the remaining services at issue. 
 
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 fillings up to you $500 annual maximum.  
 
We looked at the file and Medicare rules. Though the Plan offers dental benefits in excess of Medicare 
coverage, the core buildup and crown are not among those covered services. The Plan provided documentation 
showing that the remaining amount in your dental allowance was applied to your crown provided on March 18, 
2021, and the remaining amount over the dental allowance is not covered by the Plan. Therefore, we decided 
that the Plan does not have to provide additional payment for the core buildup, including any pins when 
required (D2950), crown - porcelain fused to high noble metal (D2750), resin-based composite - two surfaces, 
posterior (D2392), and resin-based composite - one surface, posterior (D2391) provided March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutments (D6057) for tooth #11 
provided on November 16, 2021. 
 
You asked the Plan to pay for the custom fabricated abutments for tooth #11. You say that according to your 
plan benefits, crowns and bridges are covered at 50%. The Plan denied your request. The Plan says the 
maximum benefit for 2021 was $3,000, and for benefit year 2021 you only had $1,894 left when your appeal 
was filed. 
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 Plan offers a maximum calendar 
year benefit of $3,000. The record shows that you met the annual maximum benefit while reprocessing this 
claim for the November 16, 2021 date of service and your annual maximum benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutments (D6057) for tooth 
#11 provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that your previous dentures were lost 
and you need new ones. The Plan denied your request. The Plan says you will exceed the frequency limit for 
this 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. The Plan covers a complete 
upper denture once every five years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture was 
previously covered on August 23, 2018. Based on this information, we decided that the Plan's frequency limit 
for coverage of a complete upper denture would be exceeded with the requested service. Therefore, we decided 
that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), deep 
sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 
15-minute increment (D9223). 
 
You asked the Plan to pre-approve removal of torus mandibularis and deep sedation/general anesthesia. You 
say that you need a denture and must get this service done first. The Plan denied your request. The Plan says 
this service is not covered under your benefits. 
 
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 pre-approve removal of torus mandibularis (D7473), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional 
oral exam provided on October 27, 2021, and November 24, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and additional oral exam. You say that you 
are entitled to two exams per year. The Plan denied your request. The Plan says these services exceed your 
plan's frequency limitations for oral exams. The Plan also says that exams are limited to twice per calendar 
year. 
 
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, oral examinations are limited to two 
per calendar year. The record shows that you received oral exams on June 30, 2021, and October 25, 2021 and 
your oral examinations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and additional oral exam provided on October 27, 2021, and 
November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (CPT code 99100) 
provided on May 29, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT 
code 99100, which as a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled 
into payment for other services not specified and no separate payment is made per Medicare. Therefore, we 
decided that the Plan does not have to pay for the anesthesia for patient of extreme age (CPT code 99100) 
provided on May 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles for a wheelchair (K0108). 
 
You asked the Plan to pre-approve push handles for a wheelchair. You say that you would like this item 
approved for coverage. The Plan denied your request. The Plan says the requested push handles do not serve a 
medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve push handles for a wheelchair (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2750 x2) provided on November 23, 2021. 
 
You asked the Plan to pay for the crowns. You say that you had no reason to believe crowns would not be 
covered in 2021 because they were completely covered in 2020. You also say that you received no notification 
that crowns were not covered. The Plan denied your request. The Plan says this procedure is not covered under 
your dental plan. The Plan also says that when you contacted the Plan on November 11, 2021, you only asked 
for your maximum benefit amount and did not ask if crown services were 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 two 
crowns (D2750 x2) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from March 23, 2021, to August 
27, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the dental services. You say that this dental work was done by a licensed dentist, 
and you expect a $1,500 reimbursement. The Plan denied your request. The Plan says you received these 
services from a provider who chose not to receive Medicare funds. The Plan also says that this treating provider 
opted out of Medicare effective September 22, 2015, to September 22, 2023. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the dental services provided from March 23, 2021, to August 27, 2021 by a 
Medicare opt out provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on October 8, 2020. 
 
You asked the Plan to pay for the services provided. You say that the claim lines should be paid. The Plan 
denied your request. The Plan says the codes are not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 52442 is cystourethroscopy, with insertion of permanent 
adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately 
in addition to code for primary procedure). We find that 4 units of code 52442 were billed on the date of 
service at issue. We find that 4 units are not supported in the medical records.  
 
In this case, the CPT Code Manual definition of code 96365 is Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. We find that CPT code 96365 was an integral to 
accomplishing the primary procedure. Services that are integral to a more comprehensive procedure should not 
be unbundled. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided 
on October 8, 2020.