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

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355) by an out-of-network 
provider on July 5, 2021. 
 
You asked the Plan to pay for a full mouth debridement. You say that this should be covered. The Plan denied 
your request. The Plan says the rendered dental service is not a covered 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 pay for a full 
mouth debridement (D4355) by an out-of-network provider on July 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
admission. The Plan denied your request. The Plan says Long-Term Acute Care admission is not medically 
necessary because the enrollee can continue to receive care in the current inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but would be available at the LTACH facility. 
 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from April 1, 2021, 
through April 17, 2021, billed with code CAGE1. 
 
You asked the Plan to pay for the SNF services as billed. You say that the services provided were medically 
necessary and billed correctly. The Plan denied your request. The Plan says that payment for this stay was 
reduced to the default rate due to the absence of the MDS form which is required to confirm the billed HIPPS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF admissions are paid based on the 5-digit 
HIPPS code which is calculated from information on the MDS assessment. The rules also say that Plans must 
make diligent efforts to gather and forward information to support their determinations.  
 
In this case, we received a copy of the MDS form which was not submitted during the Plans review. The 
record does not show that the Plan made efforts to obtain this during the appeal time frame of 60 days, and the 
case was forwarded to Maximus before the 60-day time frame expired. Since the Plans denial rationale was 
based solely on the absence of the MDS form, which is now in the record, we find that the denial of payment is 
no longer supported. Based on this information, we decided that Medicare rules for coverage of the SNF 
services as billed have been met. Therefore, we decided that the Plan has to pay for the skilled nursing facility 
(SNF) services provided from April 1, 2021, through April 17, 2021, billed with code CAGE1.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on February 15, 2022. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you benefit 
maximum has been met. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every year. 
 
 We looked at the file and the Plan's rules. The file shows that you used the eyewear benefit on March 24, 2021, 
and on March 25, 2021. The eyewear benefit maximum has been met. Therefore, we decided that the Plan does 
not have to pay for eyeglasses provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of benign lesion greater than 1.25 cm. (D7411) 
provided January 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you was referred by your primary dentist to an 
oral surgeon for consult. The office told you that if you wanted coverage you would have to pay the total bill 
before the surgery then file to the Plan for medical reimbursement. The Plan denied your request. The Plan says 
the claim/service lacks information or has submission errors. Missing/incomplete/invalid other diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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. 
 
We find that CPT D7411 is not supported in the medical record. Specifically, the Plan made multiple attempts 
to the dentist office to request the diagnosis codes without success. 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 excision of benign lesion greater than 1.25 cm. 
(D7411) provided January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opted-out dentist from August 
19, 2020, to October 14, 2020. 
 
You asked the Plan to pay for dental services. You say that you called in advance to see what the Plan would 
pay and have done what you were supposed to do. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because this provider has opted out of Medicare and is not eligible for 
payment. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The Plan contract says that supplemental dental 
services are covered when provided by any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opted-out dentist from August 19, 2020, to October 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 2, 2021, 
through July 16, 2021, billed with code 4CB21. 
 
You asked the Plan to pay for the home health services as billed. You say that this was billed correctly. The 
Plan denied your request. The Plan says the enrollee was admitted to the facility from an outpatient observation 
stay which does not warrant the reporting of the institutional admission source. 
 
The Plan must follow Medicare rules. Medicare rules say that the first digit of the home health HIPPS code 
should report institutional admission only if the enrollee was admitted from an inpatient stay. Admission from a 
hospital outpatient stay would be considered community admission.  
 
We looked at the file and Medicare rules. The record shows that the enrollee was in an outpatient hospital stay 
before admission to the home health agency. Based on this information, we decided that Medicare rules for 
coverage of the home health services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from July 2, 2021, through July 16, 2021, billed with code 
4CB21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided to the enrollee from February 26,
2020, to March 23, 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 show the enrollee had another primary insurer at the time of service and this
claim must be reviewed by them first. Maximus overturned the Plans denial because the case file lacked proof
of the enrollee's coverage at the time of service. The Plan requested a reopen and provided a screen shot of the
Medicare data base showing the enrollee did indeed have a separate primary insurer at the time of service.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that Medicare plans are
considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not
responsible for paying for services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the
Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the
primary insurer at the time of service and provided instruction on submitting the claim correctly. As the
secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied
the claim for these services. Therefore, we decided that the Plan does not have to pay for vision services
provided to the enrollee from February 26, 2020, to March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided August 6, 2020. 
 You asked the Plan to pay for the orthosis. You say that you have attached all the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says the documentation indicates services 
are not necessary for treatment of the enrollee's condition 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee is a 66-year-old male with chronic low back pain and 
polyneuropathy. The review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for lumbar sacral orthosis (L0650) provided August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
February 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would appreciate if the services were paid 
in full. The Plan denied your request. The Plan says the crown and core build up 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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) for durable medical equipment provided 
November 18, 2021. 
 
You asked the Plan to pay for sales tax. You say that you are requesting reconsideration of the CPAP and 
CPAP filters as you are treating the enrollee for obstructive sleep apnea and it is medically necessary for him to 
continue it. The Plan denied your request. The Plan says sales tax is not a covered by Medicare or the Plan.  
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. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
(S9999) for durable medical equipment provided November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fiberglass cast supplies provided to the enrollee on December 
15, 2021. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted medical records indicate that short arm cast was dispensed; however, the records 
do not indicate that it was of fiberglass. 
 
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 Q4010 is "Cast supplies, short arm cast, adult (11 years 
+), fiberglass." 
 
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 supplies. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the review has determined that the 
records did not support that the short arm case that was provided in this case was made from fiberglass. 
 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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for fiberglass cast supplies provided to the enrollee on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 and the radiologic examination 
services coded 74230 provided on January 12, 2022. 
 
You asked the Plan to pay for the office visit and the radiologic examination services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are 
not a covered benefit. 
 
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 99204 and 74230 are not supported in the medical record. Specifically, the 
documentation shows that the services rendered were performed in a nursing home place of service (via mobile 
van/portable x-ray), which is an axcluded place of service. Based on this information, we decided that 
Medicare rules for coverage of the office visit and the radiologic examination services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 and the radiologic 
examination services coded 74230 provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services you received on December 1, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware you were at the 
calendar year maximum, so you would like additional payment. The Plan denied your request. The Plan says 
you have exhausted your dental benefit for 2021. 
 
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. Your Plan's dental benefit 
includes coverage of dental services up to $1500 per year. Members are responsible for any amount over and 
above this allowance.  You had exhausted this $1500 per year benefit on the date of service in question.  
 
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 more for dental services you received on December 1, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an intra-abdominal omental flap (procedure code 49905) provided to 
the enrollee on September 22, 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 that the records do not support the use of procedure code 49905. 
 
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 49905 is "Omental flap, intra-abdominal (List separately in addition to code for primary procedure)." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the medical documentation does support 
the use of the add-on code CPT 49905. The statement in the document says "an omental flap was created off 
the transverse colon. This was taken to the posterior to the stomach and tacked into position reinforcing the 
closure." The closure they are addressing is that of the perforation site from the hernia. Reviewing the CPT 
guidance of the procedure code is that the "Provider repositions a flap of omentum to fill a defect during an 
abdominal surgery. He rotates the flap into place, without disrupting vascular supply, staples or sutures into 
place an continues with primary surgery."  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
an intra-abdominal omental flap (procedure code 49905) provided to the enrollee on September 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says the requested service is not a covered 
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 a 
mandibular partial denture (D5214) provided by a participating provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency services provided on January 31, 2022. 
 
You asked the Plan to pay for the emergency services. You say that you were granted temporary certification 
by Medicare as an emergency room during the public health emergency. The Plan denied your request. The 
Plan says that services provided by a non-Medicare certified facility are not covered. 
 
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. Specifically, the Plan's sole denial rationale is that you are not a Medicare-
certified provider.  However, you provided the Plan with a letter from the Centers for Medicare and Medicaid 
Services (CMS) dated May 18, 2020, that explicitly granted you a CMS certification during the public health 
emergency.  The Plan has failed to address this letter at all.  It doesn't appear that the Plan ever reviewed or 
commented on this letter, which is dispositive in this case.  Due to the Plan's failure to do so, we find that the 
Plan has not supported its denial in this case. Therefore, we decided that the Plan has to pay for emergency 
services provided on January 31, 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.