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

 
We decided that the Plan has to pay for the laboratory services provided on September 14, 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 that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on September 14, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spinal puncture services (62328) provided on January 21, 
2022. 
 
You asked the Plan to pay for spinal puncture services. You say that you would like this claim reprocessed 
based on the submitted medical records. The Plan denied your request. The Plan says the documentation 
submitted does not indicate that two separate services were performed. 
 
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 a second payment for CPT code 62328 is not supported in the medical record. Specifically, the documentation does not support that two separate services were performed as billed. Based on this information, 
we decided that Medicare rules for coverage of spinal puncture services have not been met. Therefore, we 
decided that the Plan does not have to pay for spinal puncture services (62328) provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the vision services (92250 and 92004) provided on January 25, 2022. 
 
You asked the Plan to pay for the vision services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan provided no supporting evidence based on Medicare 
guidelines for review. The Plan should provide a complete case file to include any Medicare regulations to 
verify that the services were not payable as billed. The case file has no evidence based on Medicare guidelines 
that these services are not payable as billed. Therefore, we decided that the Plan has to pay for the vision 
services (92250 and 92004) provided on January 25, 2022.  
 
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 pay for the orthotic devices (L1971, L3170) provided on February 3, 
2022. 
 
You asked the Plan to pay for the orthotic equipment. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records from the enrollees provider do not feature the provider discussing 
the need for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the orthotic devices (L1971, L3170) provided on February 3, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from September 26, 2021, to 
September 30, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that you would like to be reimbursed for 
this stay. The Plan denied your request. The Plan says that the records indicate that you no longer required the 
services of skilled nursing. The Plan also says that you chose to stay at facility as a custodial patient. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 25, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for the skilled nursing services provided from September 26, 2021, to September 30, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from October 5, 2021, 
through January 24, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you were told the Plan would pay something 
on this. The Plan denied your request. The Plan says the claim processed correctly. 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture was not provided for chronic low back 
pain. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from October 
5, 2021, through January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided December 2, 2021. 
 
You asked the Plan to pay for the core buildup. You say that you would have waited to have the service done if 
you had known it would be denied. The Plan denied your request. The Plan says you have exhausted your 
dental allowance for 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the core 
buildup up to the $2,500 dental annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $2,500 
annual maximum has been applied to your dental claims in 2021. You have been asked to pay the full cost of 
the core buildup because this cost exceeds your annual maximum. Therefore, we decided that the Plan does not 
have to pay for the core buildup, including any pins when required (D2950) provided December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. The Plan denied your request. 
The Plan says this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported cast metal crowns (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. You say that you had an 
approval for the implants and now you need the crowns to cover them. The Plan denied your request. The Plan 
says this service is not covered under your 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported cast metal crowns (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) provided January 6, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that the 
Plan contract shows that one crown will be covered. 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 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 the 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) provided January 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from September 25,
2020, to October 2, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans
denial for a lack of medical records in the file. The Plan requested a reopen and provided medical records.
Our Medical Director looked at the case file and the reopen request. At issue reconsideration of a diagnosis
related group (DRG) adjustment. The medical records show the enrollee was a then 85-year-old woman with a
history of diet-controlled type 2 diabetes, hypertension, and stage IV chronic kidney disease, who presented to
the Emergency Department on September 25, 2020, with cough and weakness. Vital signs were notable for
hypertension. The enrollee was treated with oxygen, 2 liters, via nasal cannula. The enrollee was diagnosed
with suspected COPD exacerbation and chronic kidney disease, stage IV. The enrollee's renal function was at
baseline. A computed tomography angiogram was performed and demonstrated no acute findings other than
minimal dependent atelectasis. The enrollee's chronic kidney disease was stable. Accelerated hypertension was
treated with home medications. Pulmonary medicine noted that the right-sided elevated hemidiaphragm was
the likely cause of the enrollee's hypoxia. "This is chronic and nothing to be done while she is inpatient." The
plan was to continue to wean down FiO2. The enrollee was diagnosed with acute hypoxic respiratory failure
likely due to restrictive lung disease secondary to right-sided elevated hemidiaphragm. The discharge diagnosis
was listed as "Acute respiratory failure with hypoxia; chronic kidney disease." DRG 205 is not supported based
on the records provided. DRG 205 is listed as "Other respiratory system diagnoses with major complication or
comorbidity." DRG 206 is listed as "Other respiratory system diagnoses without major complication or
comorbidity." For the purposes of coding, a complication is a condition that arises during a hospitalization that
prolongs the length of stay. A comorbidity is a pre-existing condition that affects the treatment received and/or
prolongs the length of stay, because of its presence as a secondary diagnosis along with a specific principal
diagnosis. The documentation in the case file does not sufficiently support that the enrollee in this case had a
major complication or comorbidity that affected the enrollee's treatment and/or prolonged the enrollee's length
of stay.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided to the enrollee from September 25, 2020, to October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063 x 12), 
and implant supported porcelain crowns (D6065 x 12). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from coverage. 
 
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 dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported cast metal crowns (D6063 x 12), and implant supported porcelain crowns (D6065 x 12).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you cannot chew or eat because you do 
not have the upper part of your teeth. The Plan denied your request. The Plan says this service is not covered 
under your 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750), prefabricated posts and cores (D2954) 
and root canals (D3330). 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary, and 
you cannot afford this care without insurance. The Plan denied your request. The Plan says you have met your 
$1,000 benefit allowance for comprehensive dental services this year and are responsible for any amount that 
exceeds this allowance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $1,000 
per year for comprehensive dental care. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, these items or services exceed your 
Plans annual $1,000 coverage limit for 2022. Therefore, we decided that the Plan does not have to pre-approve 
a crown (D2750), prefabricated posts and cores (D2954) and root canals (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), and panoramic 
radiographic image (D0330) provided February 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral exam, bitewing x-rays, dental cleaning and panoramic x-
ray provided OON. You say that your provider did not tell you that your dentist retired and the office is now 
OON. The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral exam, bitewing x-rays, dental cleaning and panoramic x-ray provided OON when the 
services are provided in-network.  
We looked at the file and Medicare rules. The services in this case were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the comprehensive oral exam, bitewing x-rays, 
dental cleaning and panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic 
images (D0274), prophylaxis - adult (D1110), and panoramic radiographic image (D0330) provided February 
7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve lower extremity orthotic equipment (L2275, L2755, L2820). 
 
You asked the Plan to pre-approve lower extremity orthotic equipment. You say that this equipment is 
necessary for the enrollee's functioning. The Plan denied your request. The Plan says that the requested 
equipment is only covered once in a beneficiary's lifetime. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage for the requested equipment because 
they state it is only covered once in a lifetime. There is no evidence presented that Medicare only covers this 
equipment once in a lifetime. In addition, although approval letters were attached no claim forms were 
provided to indicate the enrollee received this equipment. Therefore, we decided that the Plan has to pre-
approve lower extremity orthotic equipment (L2275, L2755, L2820).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis (74177) to be provided at a tertiary care facility. 
 You asked the Plan to pre-approve a CT provided at a tertiary care facility. You say that you would like to go 
to the same office where you are being seen by the gastroenterologist, and do not want to be seen at a different 
location. The Plan denied your request. The Plan says the records do not show that you require a tertiary CT 
imaging at the tertiary level of care. The Plan also says that based on the provided records, conditions for 
tertiary care services are not met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 CT provided at a tertiary care facility. 
Our reviewer says that the CT scan requested at a tertiary care facility does not meet criteria. Our physician 
reviewer found while you have a variety of medical conditions, the provided record does not support the 
medical necessity for specialty care outside of the plan provider network, nor that network providers are 
unavailable or inadequate to meet the medical needs relative to the CT scan requested. 
 
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 CT provided at a tertiary care facility have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis 
(74177) to be provided at a tertiary care facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services provided to the enrollee on 
December 14, 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 only one hospital discharge day management service is payable per patient per hospital stay. 
 
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 99238 is "Hospital discharge day management; 30 
minutes or less." 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, it is not appropriate to bill 
these types of codes twice in one day. The case file shows that CPT 99239 was already billed for 12/14/21. 
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 hospital discharge services provided to the 
enrollee on December 14, 2021.