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

 
We decided that the Plan does not have to pre-approve an implant supported crown on tooth #3 (D6066). 
 
You asked the Plan to pre-approve the crown. You say that you have already half of the procedure done and 
your surrounding teeth are in pain. The Plan denied your request. The Plan says dental implants and all 
associated services are not covered by 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 pre-approve an 
implant supported crown on tooth #3 (D6066).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on 
October 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was submitted for the panel. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on 
October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry services (83789) provided on 
November 8, 2021. 
 
You asked the Plan to pay for the mass spectrometry services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed 
with an appropriate modifier to bypass the NCCI edit. 
 
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 83789 
is a column II code to column I code 80307. 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 mass spectrometry services (83789) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010), custom abutments (D6057), 
guided tissue regeneration (D4266), abutment supported crown (D6059) and a bone replacement graft (D4263). 
 
You asked the Plan to pre-approve dental services. You say that you were approved for some of these services 
before, but you needed other treatment first. Now, these services are not covered, but you already started 
treatment and this care is necessary. The Plan denied your request. The Plan says these services are not covered 
by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants (D6010), custom abutments (D6057), guided tissue regeneration (D4266), abutment supported 
crown (D6059) and a bone replacement graft (D4263).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined that the enrollee had documented skilled therapy needs. The
enrollee was noted to be functioning below baseline. The Plan requested a reopen and stated that the records
show the enrollee was wheelchair bound, and that he had not walked for at least a couple of years. The medical
records show the enrollee required maximal assistance with bed mobility and lower extremity dressing. The
Plan is correct in this case. The documentation does not support that it was medically reasonable and necessary
to provide skilled services to the enrollee in this case daily on an inpatient basis, in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The
Maximus Physician Reviewer determined that you had documented skilled therapy needs and was functioning
below your reported baseline. The Plan requested a reopen and argued that your care was at a custodial level of
care. "Unavailability of competent caregivers to provide non-skilled services, no matter how important the
services are, do not make them skilled even if a therapist furnishes those services. Medicare mandates that the
patient's needs be met at the lowest level of care."
The Plan is correct in this case. The documentation does not support that it was medically reasonable and
necessary to provide skilled services daily on an inpatient basis in a SNF. Medicare coverage criteria were 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heavy-duty lightweight wheelchair (K0004). 
 
You asked the Plan to pre-approve the heavy-duty lightweight wheelchair. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a heavy-duty light weight wheelchair is covered when 
the beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be 
performed in a standard or lightweight wheelchair.   
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 heavy-duty lightweight wheelchair. 
Our reviewer says that the requested heavy-duty lightweight wheelchair is not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 58-year-old female with the medical history of type II 
diabetes mellitus, congestive heart failure and cardiomyopathy, seizure disorder, end stage renal disease, 
deconditioning and pressure sores. There is limited clinical documentation regarding the patients current 
functional status with regards to performing activities of daily living, performing pressure relief and mobility. 
Additionally, there is little to no physical examination documentation provided in terms of the patients motor 
strength and range of motion. Without this documentation, the requested heavy-duty lightweight wheelchair 
will be considered not medically reasonable and 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 heavy-duty lightweight wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the heavy-duty lightweight wheelchair (K0004).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Keytruda at 400 mg, once every 14 days for
cycles 5-11, then every 28 days for cycle 12, and then every 42 days for cycles 13-17.
You asked the Plan to provide coverage for a specific dosage of Keytruda. You say that this dosage is
medically necessary. The Plan denied your request. The Plan says while the drug is covered, the dosage is not.
Maximus overturned the Plans denial but did not address the dosage requested. The Plan requested a reopen
and stated that Maximus did not address the correct issue upon appeal.
Our Medial Director looked at the case file and the reopen request. At issue is coverage for Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that the enrollee met the criteria for
Keytruda. The Plan requested a reopen and noted they approved the drug but not the requested dosage. The
medical records show the enrollee is a 73-year-old woman with a diagnosis of Malignant neoplasm of the
esophagus, unspecified.
The case file contains a Medicare Medical (Part B) Prior Authorization form which contains documentation of
a new request for Keytruda at a dose of 400 mg, once every 14 days for cycles 5-11, then every 28 days for
cycle 12, and then every 42 days for cycles 13-17.
Our Medical Director has concluded that the Plan is correct in this case. Per NCCN, Pembrolizumab is a
preferred regimen for second-line therapy for esophageal squamous cell carcinoma with PD-L1 expression
levels by CPS of greater than or equal to 10. However, the requested dosing schedule is not consistent with the
FDA-approved label, is not supported in the compendia. In addition, the requested dosage is not found to have
support in peer-reviewed published literature. Medicare coverage criteria are 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 requested dosage are not met. Therefore, we decided that the Plan does not
have to pre-approve 400 mg, once every 14 days for cycles 5-11, then every 28 days for cycle 12, and then
every 42 days for cycles 13-17.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to provide coverage for SNF services. You say that at the time of the appeal, SNF services
were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met. Maximus 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 SNF services. The
Maximus Physician Reviewer determined the documentation supports daily skilled services were needed, and
that SNF care was reasonable and necessary. The Plan requested a reopen and argues that the rationale does not
appear to speak to documented recommendations in the chart that indicate that the enrollee did not require daily
skilled therapy. The Plan notes that both physical and occupations therapy note only recommended therapy 1 to
2 times per week. The Plan further notes that Medicare does not require a patient to have plateaued in function.
The medical records show the enrollee is a 100-year-old woman with a medical history that included severe
aortic stenosis, atrial fibrillation, hypertension, and Alzheimer's dementia. The Plan is correct in this case. The
clinical documentation does not support that it was medically reasonable and necessary to provide skilled
therapy services on a daily basis on an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reprocess the claim for the emergency room services, and self-
administered drugs provided from November 2, 2021, through November 23, 2021. 
 
You asked the Plan to reprocess the claim for the self-administered drugs. You say that the copayment should 
have been waived and the self-administered drugs should have been covered. The Plan denied your request. 
The Plan says the copayment has processed correctly, and the self-administered drugs have denied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $90 copayment for Emergency care.  
 
The enrollee has been asked to pay a $90 copayment for the emergency room services. The emergency room 
services fall within the emergency care benefit category. Although the documentation shows that multiple days 
were spent in the hospital, this care was observation care, and the enrollee was not admitted inpatient. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
 
In addition, 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 reprocess the claim for the emergency room services, and self-
administered drugs provided from November 2, 2021, through November 23, 2021.  
 
Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug test (G0483) provided February 8, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not contain 
documentation to support the coding criteria. Documentation does not support 22 or more drug classes.
 
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 G0483 is Drug test(s), definitive, utilizing drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any 
type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic 
methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity 
testing, per day, 22 or more drug class(es), including metabolite(s) if performed. 
 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 laboratory service. Our reviewer says that the requested 
items/services are not considered supported in the medical records, in this case. Our reviewer found the review 
indicates that the plan denied G0483 as the records do not contain documentation to support the coding criteria. 
Documentation does not support 22 or more drug classes. The review has determined that the use of G0483 
was not supported by the medical records. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug test (G0483) provided February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This item is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cast partial (5213P) provided on February 3, 2022. 
 
You asked the Plan to pay for a cast partial. You say that you believe this dental service should be covered. The 
Plan denied your request. The Plan says a cast partial (5213P) is not covered by 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 cast 
partial (5213P) provided on February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided 
on December 16, 2021. 
 
You asked the Plan to pay for ultrasonic guidance. You say that these services were billed appropriately. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 20611 and 76942. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed appropriately by Medicare coding regulations. 
 
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 76942 
is a column II code to column I code 20611. 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 ultrasonic guidance for needle placement (76942) provided on 
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and implant-supported 
crown (D6065). 
 
You asked the Plan to pre-approve dental services. You say that you received these services in the past and it is 
necessary to have them replaced at this time. The Plan denied your request. The Plan says these services are not 
covered by your 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, 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 
custom abutment (D6057) and implant-supported crown (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve dentures. You say that the denture you have is damaged. You say that it is 
very old. You also say that you need a new one to eat properly. The Plan denied your request. The Plan says 
dentures are covered once every 60 months. The Plan also says that the frequency limit has been reached. 
 
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 and dentures are covered once every 60 
months, the frequency limit has been reached. The record shows that the Plan paid for complete dentures that 
you received on October 5, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation services (D9222, D9223 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you have to have your broken teeth 
extracted. You also say that you cannot stay awake during the procedure. The Plan denied your request. The 
Plan says deep sedation services are not listed as covered services. 
 
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 deep sedation services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve deep sedation services (D9222, D9223 x 3).