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

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) and guided tissue 
regeneration (D4266), provided on July 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be paid. You also 
say that at least the surgical portion should be paid. The Plan denied your request. The Plan says bone 
replacement graft is not listed as a covered dental service. The Plan says guided tissue regeneration is not listed 
as a covered dental service either. 
  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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) and guided tissue regeneration (D4266), provided on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of romiplostim. 
 
You asked the Plan to pre-approve romiplostim. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
enrollee's platelet levels are higher than what is needed to start treatment and the dose requested exceeds the 
recommended dose. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 romiplostim. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of romiplostim. Our physician reviewer 
found the requested use of romiplostim is not Food & Drug Administration (FDA) approved for the enrollee's 
diagnosis. This use is not supported by one of the major drug compendia or by clinical research appearing in a 
Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of romiplostim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of romiplostim.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the 
enrollee on June 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 70544 is "Computed tomography, head or brain; without 
contrast material." 
 
We find that CPT code 70544 is not supported in the medical record. Specifically, this code cannot be billed 
separately from CPT 70496 without the appropriate modifier. 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 imaging services (procedure code 70450) provided to the enrollee on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for total shoulder
arthroplasty and biceps tenodesis.
You asked the Plan to provide coverage for inpatient admission. You say that inpatient care is medically
necessary. The Plan denied your request. The Plan says Medicare criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient
admission for total shoulder arthroplasty and biceps tenodesis. The Maximus Physician Reviewer determined
that the reverse left total shoulder arthroplasty was supported. The enrollee had a significant past medical
history including asthma, high cholesterol, hypertension, and diabetes. These co-morbidities plausibly (in
combination) significantly increase the risk of peri-operative complications. Therefore, the request for inpatient
hospital admission for total shoulder arthroplasty was determined to be medically reasonable and necessary.
The Plan has requested a re-opening, citing an error on the face of the evidence. The plan has stated that it
disagrees with our consultant's determination. The plan argues that despite the enrollee's medical history, there
is no reason she could not be initially monitored within the ambulatory/observation setting. The plan notes that
the enrollee could be changed to inpatient status based upon any operative or post-operative concerns.
The medical records show the enrollee is a 65-year-old woman with Unspecified rotator cuff tear or rupture of
left shoulder, not specified as traumatic. The medical history was notable for diabetes, hypertension, asthma,
and degenerative joint disease. The enrollee's medications include aspirin, lisinopril, metformin, rosuvastatin,
and tizanidine. The enrollee's blood pressure was normal on June 24, 2021. The Plan is correct in this case.
While the enrollee had multiple medical problems, there was no evidence that her conditions were poorly
controlled and would have necessitated inpatient admission. The documentation supports that it would have
been reasonable to admit the enrollee to observation status, and adjust the status based on her clinical course.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does
not have to provide coverage for inpatient admission for total shoulder arthroplasty and biceps tenodesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vaccine for tetanus and diphtheria toxoids provided on June 
16, 2021. 
 
You asked the Plan to pay for the vaccine services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this vaccine is not covered unless it is 
directly related to the treatment of an injury or direct exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for vaccine for tetanus and diphtheria 
toxoids provided on June 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan/Supartz (J7321). 
 
You asked the Plan to pre-approve Hyaluronan/Supartz. You say that you would like to appeal this drug 
because you have pain in your knees. The Plan denied your request. The Plan says the records do not indicate 
that you have tried and failed Synvisc and Synvisc-one. The Plan also says there is no documentation showing 
that you cannot take the preferred medications, or there is a medical reason why the preferred drugs would not 
be as effective as the non-preferred drug requested.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyaluronan/Supartz. Our reviewer says 
that Hyaluronan/Supartz is not medically necessary. Our physician reviewer found the Plan requires a trial of 
drug Synvisc and Synvisc-one before they will approve the requested drug. Our reviewer found that in this 
case, you have not tried and failed the required drugs. Our physician reviewer also found that there is no 
documentation indicating that the Plan?s required drugs would likely be less effective and/or likely have 
adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan/Supartz have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyaluronan/Supartz (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided 
on April 18, 2021. 
 
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records provided do not support the billing 
of code 99291. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress note for April 18, 2021 does not note how much time was spent 
providing services to the enrollee. As such, the provided documentation does not support the billing of code 
99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been 
met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 
99291 provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820) provided on July 15, 2021.

You asked the Plan to pay for dental code D5820. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D5820 is not covered under the Plan's supplemental dental benefit.

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, dental code D5820 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim partial denture (D5820) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on April 9, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says the claim has not been billed with the 
appropriate modifier. 

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 99213 
is a column II code to column I code 77263. 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 the office visit (99213) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and take-home 
medication (D9630) provided on June 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised that the services you received 
needed to be pre-authorized. You say that you were not aware of this policy for dental. You say that you feel 
these services should be covered. The Plan denied your request. The Plan says gingival irrigation is not listed 
as a covered service. The Plan says that take-home medication is not listed as a covered service either. 
 
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 gingival irrigation and drugs or 
medicaments are not among those covered under this benefit. The record shows that you signed a treatment 
plan showing $0 insurance coverage for the gingival irrigation, and primary coverage of $15 for take-home 
medication with $0 coverage for take-home medication by your secondary coverage. The treatment plan also 
shows that you acknowledge that you would be responsible for the charges for these services. Therefore, we 
decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and take-home medication 
(D9630) provided on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to additional reimbursement for a stair lift purchased on April 10, 2021. 
 
You asked the Plan to additional reimbursement for a stair lift. You say that you want to stay in your home and 
this stair lift was medically necessary to go up and down the stairs. You stated the cost was almost $10,000 and 
you expected more reimbursement from the Plan. The Plan denied your request. The Plan says stair lifts are not 
covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. It should be noted that any reimbursement given by the Plan may have 
been done so as a courtesy and none was required since this equipment is never covered by Medicare. 
Therefore, we decided that the Plan does not have to additional reimbursement for a stair lift purchased on 
April 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) 73221 of the 
right shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of 
the requested service. The Plan denied your request. The Plan says the request does not meet the criteria for 
medical necessity as there is no clinical documentation that indicates the enrollee has trialed at least 6 weeks of 
either physical therapy or home exercise. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records did not clearly show the enrollee had fully exhausted physical therapy or 
home exercises for the right shoulder, nor was there physical findings suggestive of a red flag diagnosis 
warranting earlier imaging. Therefore, the MRI will be considered not medically necessary based on the 
provided documentation. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) 73221 of the right shoulder.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging of cervical spine 
(72141) and magnetic resonance imaging of the lumbar spine (72148). 
 
You asked the Plan to pre-approve the MRI of the cervical and lumbar spine. You say that the medical records 
provided support the necessity of the requested service. The Plan denied your request. The Plan says the 
records do not support that the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the cervical and lumbar 
spine. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation of adequate conservative 
measures to include medications and physical therapy. The criteria for MRI of the cervical and lumbar spine 
not met. 
 
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 MRI of the cervical and lumbar spine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the magnetic resonance imaging of cervical spine (72141) 
and magnetic resonance imaging of the lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) 
and non-intravenous conscious sedation (D9248) provided on April 22, 2021. 
 
You asked the Plan to pay for the scalings and planings and non-intravenous conscious sedation. You say that 
you contacted the Plan prior to receiving these services and were quoted that you had $1,000 to use towards 
dental services. You also say that this procedure was imperative for your dental and oral health. The Plan 
denied your request. The Plan says these services are not covered. The Plan also says that you did not contact 
the Plan prior to the services being rendered to verify benefits and provider eligibility. 
 
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 
periodontal scalings and root planings (D4341 x2) and non-intravenous conscious sedation (D9248) provided 
on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee. 
 
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 medically necessary based on the clinical information. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found from the documentation provided, it is unclear which radicular level is involved. An epidural steroid is 
not indicated for facet mediated pain or localized metastatic disease. The request is not medically reasonable or 
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 a lumbar epidural injection for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services (95955, 95940, 95938, 95937, 
95927, 95908 and 95885) provided on February 1, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration 
because this member was treated in and in-network facility and the member had no choice regarding which 
ancillary providers or physicians provided services. The Plan denied your request. The Plan says this provider 
is not a recognized facility or a legally qualified physician and billing agents and third-party vendors do not fall 
within the category of eligible providers, services are not payable under the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the neuromonitoring services have not been met. Specifically, the record indicates that this member 
was registered inpatient. Payment for the neuromonitoring services are the responsibility of the facility to any 
vendor. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services (95955, 
95940, 95938, 95937, 95927, 95908 and 95885) provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 25, 
2021.