Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 additional PT visits. You say that you have been trying different 
modalities with physical therapist but feels you are not where you should be with mobility. You say that you 
cannot do all of your home exercise program at home. You say that you are in pain from having surgery. You also say that you feel additional visits are necessary. The Plan denied your request. The Plan says the additional 
PT visits are not medically necessary. 
 
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 6 additional PT visits. 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 that the documentation does not reveal that the enrollee 
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 by or under the supervision of a 
therapist. The reviewer found that the enrollee was instructed on a home exercise program. The requested 
services are not part of a maintenance program and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient'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 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility services for the enrollee
beyond December 30, 2021.
You asked the Plan to provide coverage for skilled nursing facility (SNF) services.. You say that at the time of
the appeal, skilled nursing facility services were medically necessary for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the
Plans denial because a signed notice of non-coverage was not included in the records. The Plan requested a
reopen and provided a copy of the required notice.
Based on the medical records provided, the Plan is correct in this case. The Plan must follow Medicare rules.
The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section
are met. Custodial care is not covered. As of December 28, 2021, the enrollee no longer needed daily skilled
nursing or daily skilled therapy services at in inpatient SNF level of care. The enrollee was given appropriate
notice that coverage would end on December 30, 2021. Therefore, we decided that the Plan does not have to
pre-approve skilled nursing facility services for the enrollee beyond December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you are unable to afford the services. 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 core 
buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on September 13, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the treatment provided was medically necessary and 
essential for the betterment of the enrollee's health. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided on 
September 13, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that physical therapy will allow the enrollee 
a better quality of life than without therapy. The Plan denied your request. The Plan says additional PT visits 
are not medically necessary. 
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 8 additional PT visits. 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 documentation does not reveal that the enrollee 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 by or under the supervision of a therapist. The 
reviewer found that the enrollee was instructed on a home exercise program. The requested services are not 
part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the patient'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 8 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility care for the enrollee.
You asked the Plan to provide coverage for skilled nursing facility (SNF) care. You say that at the time of the
appeal, these services were medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file.
The Plan requested a reopen and provided medical records.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Based on the medical records provided, at the time of the appeal, the enrollees needs were custodial in nature.
The enrollee did not require skilled therapy or skilled nursing services at an inpatient SNF level of care.
Medicare rules for coverage of skilled nursing facility care have not been met. Therefore, we decided that the
Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound guidance used for needle placement related to post-
operative pain control on October 29, 2021, billed with code 76942. 
 
You asked the Plan to pay for the ultrasound guidance. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says that this was not billed with an appropriate modifier to bypass the edit with 
code 64454. 
 
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 76942 is Ultrasonic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation. 
 
We find that CPT code 76942 is supported in the medical record. Although there is an edit between 64454 
(genicular nerve injection) and 76942, there is no such edit between 64447 and 76942. 64447 is for an 
anesthetic block of the femoral nerve. This code does not include the imaging guidance, and the record shows 
that imaging guidance was used for the injection at the femoral nerve. As such, we find that 76942 is supported 
as an add-on code with primary code 64447. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound guidance have been met. Therefore, we decided that the Plan has to pay for the 
ultrasound guidance used for needle placement related to post-operative pain control on October 29, 2021, 
billed with code 76942.  
 
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 pay for the periodontal scalings and root planings (D4341) of the 
upper right and upper left quadrants provided on May 20, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that when you went to this appointment you 
told the attendants that the services provided should not exceed your insurance benefits because you are not in 
a position to make out of pocket payments. You also say that you should not have to pay the excess amount of 
$370.00. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the 
frequency limitation has been exceeded for these quadrants. 
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, scaling and root planing is limited to 
one procedure code every three years, per quadrant. The record shows that you received periodontal scalings 
and root planings (D4341) of the upper right and upper left quadrants on June 12, 2019 and your periodontal 
scalings and root planings (D4341) benefit for the upper right and upper left quadrants has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) 
of the upper right and upper left quadrants provided on May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) visits for evaluation and treatment 
(97110, 97163, 97167) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that you are requesting reconsideration stating you need 
both physical therapy and speech therapy. You also say in-network facilities provided are either subpar and/or 
do not have both. The Plan denied your request. The Plan says there are in-network provider(s) within a 
reasonable distance from your location that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) visits for evaluation and treatment (97110, 97163, 97167) to be provided by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pay for 6 additional PT visits. You say that having physical therapy once per week 
allows you mobility, helps your pain and allows for your independence. The Plan denied your request. The 
Plan says the additional visits are not medically necessary. 
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 pay for 6 additional PT visits. 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 provided documentation indicates that the enrollee has had prior 
therapy. The reviewer found that the documentation does not reveal that the enrollee 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 by or under the supervision of a therapist. The reviewer found that 
the enrollee was instructed on a home exercise program. The requested services are not part of a maintenance 
program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient'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 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pay for 6 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline maxillary partial denture (indirect) (D5760) and 
reline mandibular partial denture (indirect) (D5761) provided August 5, 2021. 
 
You asked the Plan to pay for the indirect reline upper and lower partial denture. You say that you were 
unhappy with the services provided by the dentist. 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 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 reline maxillary partial denture (indirect) (D5760) and reline mandibular partial denture (indirect) (D5761) provided August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), dental 
extractions (D7140) and a surgical placement of an implant body (D6010) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you are in extreme pain and was referred to an 
oral surgeon. You also say the general dentist advised you that your teeth cannot be fixed. The Plan denied 
your request. The Plan says dental services performed by an oral surgeon 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 pre-approve a 
comprehensive oral evaluation (D0150), dental extractions (D7140) and a surgical placement of an implant 
body (D6010) to be provided by an oral surgeon.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven units of ambulance ground mileage (A0425) provided 
on July 29, 2021. 
 
You asked the Plan to pay for seven units of ambulance mileage. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this code was not billed 
in accordance with Medicare rules. CPT A0425 has a Medically Unlikely Edits (MUE) value of 250, but 257 
units were billed. 250 of these units were approved and have been paid, but the remaining 7 units were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if a HCPCS/CPT code has an MUE that is 
adjudicated as a claim line edit (i.e., MAI equal to 1), appropriate use of CPT modifiers (i.e., 59 or -
X{EPSU}, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a 
claim. Each line of the claim with that HCPCS/CPT code will be separately adjudicated against the MUE value 
for that HCPCS/PCT code.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 257 total units 
of this code on a single claim line, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of seven units of ambulance mileage have not been met. Therefore, we decided that the Plan 
does not have to pay for seven units of ambulance ground mileage (A0425) provided on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
You asked the Plan to pre-approve Rhopressa. You say that the patient needs this drug to control their 
intraocular pressure and they are unable to take other medications. The Plan denied your request. The Plan says 
this drug is not covered under the patient's medical benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressa.  
 
 Benefits for Rhopressa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and seven (7) teeth extractions (D7210) to 
be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that your mouth is all cut up with your broken teeth 
causing a lot of pain. The Plan denied your request. The Plan says coverage for dental services is provided 
when they are performed by a participating general dentist. 
 
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 
evaluation and seven (7) teeth extractions (D7210) to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires ongoing 
inpatient hospital care. The Plan denied your request. The Plan says that the enrollee no longer requires an 
inpatient level of care and can be treated in an outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient services are met in this case. Our 
physician reviewer found that the enrollee with a complex medical history presented to the emergency 
department (ED) on April 7, 2022, with mental status changes. He was then admitted to the ICU. The review 
indicates that the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollees necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve continuation of acute inpatient hospital care.  
 
 
 
 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.