Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
October 27, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service.  
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 the FoundationOne CDx (F1CDx) test 
(0037U) provided October 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 8, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 psychotherapy services provided on March 8, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 an office visit provided on March 18, 2022 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on February 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
were unaware that you needed to use a specific dental provider. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that you must receive services at a 
participating provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON.  

Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-
rays (D0274), and prophylaxis (D1110) provided on February 7, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown. We also decided that the Plan does not have to pre-
approve restorative procedure and dentoalveolar surgery.  
 
You asked the Plan to pre-approve a restorative procedure, dentoalveolar surgery, and crown. You say that the 
current crown is cracked, and it is now loose. You also say you are afraid it is going to fall off. The Plan says 
that these services are not covered by your Plan's dental benefit. We decided that the Plan has to pre-approve a crown.  
 
According to the EOC, a crown (D2740) is listed as a covered service. Therefore, we decided that the Plan has 
to pre-approve a crown.  
 
We also decided that the Plan does not have to pre-approve restorative procedure and dentoalveolar 
surgery. 
 
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, a restorative procedure (D2999) and 
dentoalveolar structure surgery (41899) are not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a restorative procedure and dentoalveolar surgery. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met for E0466. 
 
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 the home ventilator. Our physician 
reviewer found the documentation supports that the home ventilator is to be used with AVAPS-AE. This 
enrollee did not fail bilevel positive airway pressure (BiPAP) therapy with AVAPS. A home ventilator such as 
the triliogy (E0466) is not eligible for reimbursement for any of the conditions described in the LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. 
A BiPAP (which the Plan has approved) can provide the appropriate settings needed to treat the enrollee. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray of unspecified side and hand/finger orthosis 
provided on October 18, 2021, billed with codes 73100 and L3923, respectively. 
 
You asked the Plan to pay for the x-ray and hand/finger brace. You say that this should be covered as the 
services were medically necessary. The Plan denied your request. The Plan says payment was approved for the 
office visit code; however, the other items are not billed correctly and cannot be paid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 73100 is for a unilateral procedure. Coding rules require that the side it is performed on be documented 
through use of a modifier, LT or RT, to indicate the side that is imaged. In addition, the reported POS code for 
the DMEPOS item (brace) was office, and not where the item is to be used. This is not one of the covered POS 
codes for DME. Based on this information, we decided that Medicare rules for coverage of the x-ray and 
hand/finger brace have not been met. Therefore, we decided that the Plan does not have to pay for the wrist x-
ray of unspecified side and hand/finger orthosis provided on October 18, 2021, billed with codes 73100 and 
L3923, respectively.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2790) and a core buildup (D2950), provided by a 
participating provider on February 10, 2022. 
 
You asked the Plan to pay for a crown and a core buildup. You say that you were told that these services would 
be covered up to $,1000. The Plan denied your request. The Plan says the rendered dental services 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 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 crown 
(D2790) and a core buildup (D2950), provided by a participating provider on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for upgrade to expandable controller (E2313) and 
an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says although there are three approved power options on this 
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
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. Therefore, we 
decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for upgrade to expandable controller (E2313) and 
an expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 a HFCWOD. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a past medical history of chronic obstructive pulmonary disease with cough. 
Based on the medical records provided there is conflicting documentation that the enrollee has a confirmed 
diagnosis of bronchiectasis. Provided records report a computed tomography scan of February 25, 2022 that 
shows emphysema and ground glass densities in both lungs. An amended report states bronchiectasis was seen 
on the scan but not reported by the radiologist. There is no documentation that show well-
documented failure of standard treatments to adequately mobilize retained secretions. Therefore, the enrollee 
does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 7,
2021, under code 99223.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information.
The Plan submitted documentation to show this claim was not bill as required by Medicare coding regulations.
The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are
reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient
hospital services. The Mutually Exclusive edit file included edits where two procedures could not be performed
at the same patient encounter because the two procedures were mutually exclusive based on anatomic,
temporal, or gender considerations. Each edit table contains edits which are pairs of HCPCS/CPT codes that in
general should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a
provider reports the two codes of an edit pair, the Column Two code is denied, and the Column One code is
eligible for payment. Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of "1"
indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.
However, an appropriate NCCI modifier was not billed with this PTP code edit. Medicare coding rules indicate
the CPT code 99223 is found under Column Two of the edit pair CPT code 39010 found under Column One.
Per Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements,
Section 20.9.3.1: A denial of services due to a Procedure-to-Procedure (PTP) edit is a coding denial, not a
medical necessity denial. Most of these PTP edit have a modifier indicator of 1, which indicates modifiers
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code
edit and Column two code is denied as the mutually exclusive procedures cannot reasonably be performed at
the same anatomic site or same beneficiary encounter. We find that the Medicare rule for payment of this claim
has not been met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when required the
appropriate modifiers. In this case, code 99223 was not billed with the appropriate modifier. Medicare rules for
coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on September 7, 2021, under code 99223.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services (81206, 81292 and 81301) provided on June 28, 2021.
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 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. We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services (81206, 81292 and 81301) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and 
prophylaxis provided on January 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
were never told that your dentist was not an approved dentist. The Plan denied your request. The Plan says you 
received self-referred services from a non-participating provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, bitewing x-rays, and prophylaxis provided on January 19, 2022 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on October 22, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the $800 maximus allowance had been exhausted. Maximus
overturned the Plans denial because documentation of the claims showing the benefit exhaustion had not been
submitted for review. The Plan requested a reopen and provided that claim documentation.
The Plan is correct in this case. Medicare does not cover dental services. The Plan covers up to $800 per year in
dental services. The documentation provided shows the $800 benefit was exhausted prior to these services.
Therefore, we decided that the Plan does not have to pay for dental services provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140). 
 
You asked the Plan to pre-approve a limited oral exam. You say that you need this service to evaluate your 
needs prior to dental extractions and to ensure you choose the correct provider. The Plan denied your request. 
The Plan says you will exceed the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers oral exam 
twice per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that oral exams were 
previously covered on February 14, 2022, and April 14, 2022. Based on this information, we decided that the 
Plan's frequency limit for coverage of a limited oral exam will be exceeded with the requested service.  
 
Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused 
(D0140).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81238, 81225, 81230, 81241, 
81291, and 81240) provided on May 25, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with 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. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81238, 81225, 81230, 81241, 81291, and 81240) provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction (D7210) to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the extraction (D7210). You say that you need the extraction done as soon 
as possible because you are experiencing pain and you are unable to eat. The Plan denied your request. The 
Plan says the service exceeded the frequency limitation in the benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit 
of up to four simple extractions per year. The requested service is not covered because the Plan preapproved 
four extractions on June 29, 2022, which exhausted your benefit. 
 
Therefore, we decided that the Plan does not have to pre-approve the extraction (D7210) to be provided by a 
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased out of network on August 28, 2020.
You asked the Plan to pay for hearing aids. You say that these hearing aids should be covered by the Plan. The
Plan denied your request. The Plan says your 2020 Plan contract did not have a hearing benefit. Maximus
overturned the Plans denial because a 2020 Evidence of Coverage had not been submitted for review. The Plan
requested a reopen and submitted a copy of the 2020 contract for review.
The Plan is correct in this case. Medicare does not cover hearing aids or related services. The Plan contract you
were a member of in August of 2020 did not have a supplemental hearing aid benefit out of network. The
records show you did not contact the Plan to confirm your hearing benefit, if any for 2020 and your provider
did not seek prior authorization for hearing aids. Therefore, we decided that the Plan does not have to pay for
hearing aids purchased out of network on August 28, 2020.