Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a Trilogy ventilator beyond two 
months (E0466). 
 
You asked the Plan to pre-approve continued use of a Trilogy ventilator. You say that you have COPD, a 
chronic lung disease. The Plan denied your request. The Plan says the request is denied as not medically 
necessary. Records do not show you are using the device more than 4 hours per day. The ventilator may only 
be medically necessary if it is used consistently. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 continued use of a Trilogy ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this device is 
approved for 2 months. At the end of 2 months, you will need to provide proof of compliance to continue 
approval for this device. It is documented that the approved is effective from September 13, 2022, to November 
12, 2022. Approval beyond November 12, 2022, cannot be determined until the 2 month period approved by 
the plan has been completed and evaluated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a Trilogy ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a Trilogy ventilator beyond two months (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230). 
 
You asked the Plan to pre-approve nitrous oxide/analgesia. You say that this was an emergency service. 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 pre-approve 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial maxillary denture (D5225) provided by a 
participating provider on June 8, 2022. 
 
You asked the Plan to pay for a partial maxillary denture. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says the rendered dental service 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 pay for a partial 
maxillary denture (D5225) provided by a participating provider on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to an expandable controller (E2313) an expandable controller (E2377) and a USB charger (K0108). 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that medical documentation has been 
submitted to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says a seat elevator and a USB charger do not serve a primary medical purpose 
and is statutorily non-covered. Although there are three approved power options/features on this wheelchair 
(tilt, recline, and elevating leg rests), there is not a medical need to control these power options/features 
through the joystick. 
 
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 a power seat elevation system (E2300), a electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to an expandable controller (E2313) an expandable controller (E2377) and a USB charger (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillofacial prosthetic appliance, a custom fabricated 
abutment, and crown restoration services (D6057, D6010, D6058) provided from April 18, 2022 to June 1, 
2022. 
 
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 
maxillofacial prosthetic appliance, a custom fabricated abutment, and crown restoration services (D6057, 
D6010, D6058) provided from April 18, 2022 to June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81295 and 81298 billed for date of service 
February 22, 2022. 
 You asked the Plan to pay for procedure codes 81295 and 81298. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says the payment for codes 81295 and 81298 is 
bundled into the payment for code 81432. 
 
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 codes 
81295 and 81298 are both column II codes to column I code 81432. Both code pairs have a modifier indicator 
of 0. The column II codes are 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 codes 81295 and 
81298 billed for date of service February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your other dentures. 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 your benefit for the requested item or service was exhausted on date of service May 20, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthesis with advanced features.
You asked the Plan to provide coverage for this request. You say that this prosthesis is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an advanced ankle-foot system (L5981, L5962). L5981 - All lower extremity prostheses, flex-walk system or equal L5962 - Addition, endoskeletal system, below knee, flexible protective outer surface covering system. The Maximus Physician Reviewer determined that the advanced foot is medically necessary.
The Plan requested a reopen and argues that there are no physician notes documenting that the enrollee is a K3 ambulator. "There is no objective clinical documentation from the physician to corroborate the vendor's claim that member requires a K3 foot." The plan notes that vendor (prosthetist) notes are not considered part of the medical record, and that letters of medical necessity are also deemed not part of the medical record. The medical records show the enrollee is a 78-year-old woman who underwent a left transtibial amputation on August 18, 2021, because of infection which led to gangrene. It is noted that the enrollee's activities include walking and traveling. The enrollee lives at home with family assistance. The Prosthetist documents that the enrollee wants to be independent with her mobility and be able to go out into the community and travel. "Patient is motivated to walk because independent mobility and self-care." The Plan is correct in this case. The case file does not contain clinical documentation supporting that the enrollee in this case is a K3 ambulator who can traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthesis with advanced features.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70553 billed for date of service May 25, 2022.

You asked the Plan to pay for procedure code 70553. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says payment for code 70553 is bundled into payment for code 70544.

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 70553 is a column II code to column I code 70544. This claim has not been billed with an appropriate modifier to bypass the edit. 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 70553 billed for date of service May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70450 and 72125) billed to the enrollee for date of service August 23, 2021, a second time.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says these services were previously paid. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan demonstrates that this claim was previously paid on October 9, 2021. The Plan states all professional services have been paid.
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, the Plan has provided documentation to show this is a duplicate claim. Therefore, we decided that the Plan does not have to pay for imaging services (70450 and 72125) billed to the enrollee for date of service August 23, 2021, a second time.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6750) and a pontic (D6240) provided by 
a participating provider on March 25, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental services are not covered 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 a retainer 
crown (D6750) and a pontic (D6240) provided by a participating provider on March 25, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87500. We decided that the Plan does not have to pay 
for procedure code 87150.  
 
You asked the Plan to pay for procedure codes 87150 and 87500. You say that these services were medically 
necessary and are supported in the medical record. The Plan says that code 87150 is not supported in the 
medical record. 
 
We decided that the Plan has to pay for procedure code 87500.  
 
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. Specifically, the Plan has not provided a clear argument or explanation as to why 
this code was denied. No evidence of a review of this code aside from one page showing that there are no 
NCCI conflicts was provided. The Plan has not substantiated the denial of code 87500 in this case. Therefore, 
we decided that the Plan has to pay for procedure code 87500.  
 
We also decided that the Plan does not have to pay for procedure code 87150. 
 
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 87150 is culture, typing; identification by nucleic acid probe, amplified probe technique, per culture or 
isolate, each organism probed. 
 
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 procedure code 87150. Our reviewer says that the records 
provided do not support the billing of code 87150. Our reviewer found that the laboratory documents a 
"Urinary Tract Infection (UTI) Pathogens 16 panel" was performed. Documentation of culture typing, 
identification by nucleic acid was not found in laboratory report, and therefore cannot be verified. In addition, 
modifier 59 would not be supported for separate payment of this code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150. 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots on tooth #11 
(D7250) and alveoloplasty (D7310). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the removal of residual tooth roots (D7250) and 
alveoloplasty (D7310) are not covered by your supplemental 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 pre-approve the 
removal of residual tooth roots on tooth #11 (D7250) and alveoloplasty (D7310).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unclassified drugs (J3490) provided during air ambulance 
transportation on September 7, 2021. You asked the Plan to pay for the ambulance supplies. You say that these services were medically necessary. 
The Plan denied your request. The Plan says they have agreed to pay for the air ambulance transport and 
mileage; however, ambulance supplies, such as drugs, are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for unclassified drugs (J3490) provided during air ambulance 
transportation on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and a mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the partial dentures. 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 your benefit for the requested item or service was exhausted on date of service March 10, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and a 
mandibular partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on October 26, 2021. 
 
You asked the Plan to pay for the dental crown. You say that the services should be covered as you disagree 
with the denial, and they are medically necessary. 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 a dental 
crown, (D2740) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820). 
 
You asked the Plan to pre-approve a maxillary interim partial denture. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary interim partial denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #10 (D2740) provided on January 11, 2022, 
a crown on tooth #1, 3, and 4 (D2740) and core build up on tooth #1, 3, and 4 (D2950) provided on February 2, 
2022, and retainer crowns on tooth #27 and 32 (D6740, D6750) provided on April 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that your insurance would cover 
these services. The Plan denied your request. The Plan says the requested services are not covered without prior 
authorization. 
 
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 must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the crowns and core build up received 
on February 2, 2022, have been met. According to the explanation of benefits, the Plan asked for additional 
information from the provider which was not received or was incomplete. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, crowns (D2740) and retainer crowns 
(D6740, D6750) are not among those covered under this benefit without prior authorization. Therefore, we 
decided that the Plan does not have to pay for a crown on tooth #10 (D2740) provided on January 11, 2022, a 
crown on tooth #1, 3, and 4 (D2740) and core build up on tooth #1, 3, and 4 (D2950) provided on February 2, 
2022, and retainer crowns on tooth #27 and 32 (D6740, D6750) provided on April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 10. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs the crown. The Plan 
denied your request. The Plan says the enrollee's 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 your benefit for the requested item or service was exhausted on date of service March 17, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for 
tooth 10.