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

 
We decided that the Plan does not have to pay for the genetic testing provided on September 20, 2021, billed 
with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311. 
 
You asked the Plan to pay for the genetic testing billed. 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 billing regulations.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 20, 2021, billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 
81311.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 11 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says you should have established an effective home exercise 
plan with the previous 21 outpatient physical therapy visits. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the clinical documentation states that the long-term goals were to 
be met in six weeks with two sessions per week with only long-term goal of pain which have not been met yet. 
There is no documentation in change of the clinical picture thus nine additional sessions would be enough time 
to form a stable home exercise plan. The requested additional 11 physical therapy sessions is medically 
unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 11 physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia Injection. 
 
You asked the Plan to pre-approve Prolia Injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia Injection. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of osteoporosis.  The record does not indicate that the enrollee is 
postmenopausal or that the enrollee is receiving the equivalent of 7.5 mg of Prednisone or greater. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia Injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia Injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. You say that facet joint interventions are medically 
necessary. The Plan denied your request. The Plan says facet joint interventions are not medically necessary 
and do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
 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 facet joint interventions. Our reviewer 
says that facet joint interventions are not medically necessary. Our physician reviewer found that the request 
exceeds utilization guidelines of two (2) RFA sessions per a 12 month period.  The request is considered not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), complete series of 
intraoral x-rays (D0210), scaling in presence of generalized moderate or severe gingival inflammation (D4346), 
and two surgical extractions (D7210 x2) provided on January 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, scaling, 
and extractions. You say that you would like these claims to be processed according to the terms of the policy. 
The Plan denied your request. The Plan says that the attending provider is non-participating and not contracted 
with the 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. 
 
We looked at the file and Medicare rules. The Evidence of Coverage (EOC) states that you are responsible for 
a 50% coinsurance for each service received OON. The contract does not clearly state what type of periodontic, 
and extraction services are covered, nor does the EOC refer you elsewhere to look for covered services. You 
reasonably believed all of these services would be covered at 50%. Based on this information, we decided that 
the Plan's rules for coverage of the comprehensive oral evaluation, complete series of intraoral x-rays, scaling, 
and extractions have been met. Therefore, we decided that the Plan has to pay for the comprehensive oral 
evaluation (D0150), complete series of intraoral x-rays (D0210), scaling in presence of generalized moderate or 
severe gingival inflammation (D4346), and two surgical extractions (D7210 x2) provided on January 8, 2022 
by an out-of-network (OON) provider.  
 
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 electrical harness, electrical accessory; joystick 
controller, seat elevator, mounting hardware, footplate pads, foot plate connector, pelvic obliquity cushion, and 
extra foam for comfort back. 
 
You asked the Plan to pre-approve the items. You say that this device and these upgrades are medically 
necessary. The Plan denied your request. The Plan says the items are not necessary. 
 The Plan must follow Medicare rules. Upgraded electronics (electronic connector) cannot be covered per 
Medicare rules. They are necessary when there is a medical need to control power options though the joystick. 
The notes do not show a medical need to control the power options through the joystick. The power options can 
be controlled using their own switches. These switches can be made any size without asking for a separate 
request. They can be made from any material without asking for a separate request. All of this can be done 
without the need to use the joystick to control the power features. The requested joystick module controller is 
included with the requested controller. A joystick controller already is included with the approved power 
wheelchair. This cannot be requested separately. The seat lift does not serve a primary medical purpose. This 
cannot be covered. The mounting hardware is incorrectly coded. The K0108 footplate pad with cover, does not 
serve a medical purpose and cannot be covered. The footplate connector, pelvic obliquity, extra foam for 
comfort back are unbundled and cannot be billed separately.  Therefore, we decided that the Plan does not have 
to pre-approve the electrical harness, electrical accessory; joystick controller, seat elevator, mounting hardware, 
footplate pads, foot plate connector, pelvic obliquity cushion, and extra foam for comfort back.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain ceramic substrate (code D2740) and 
core build up (code D2950) for tooth #19. 
 
You asked the Plan to pre-approve the crown (code D2740) and core build up (code D2950). You say that these 
services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage for these 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. The Plan covers the crown and 
core build up when the services are medically necessary and reasonable.  
 
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 crown and core build up. Our 
reviewer says that the crown and core buildup is not medically necessary. Our physician reviewer found that 
the provider indicated there was a fracture, but this is not seen on the provided x-ray. With only a small 
existing restoration and no obvious caries, and even with a small cusp fracture, there would no necessity for a crown to be placed on tooth #19. Buildups are only necessary where there is insufficient structure to retain a 
crown, when a crown is needed. That is not the case in this situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown-porcelain ceramic substrate (code D2740) and core build up (code 
D2950) for tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2950, D6752, D6242). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the dentist's notes and x-rays show that gum and bone health is not satisfactory, and 
affects the long-term outlook of the mouth. 
 
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 the services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that a bridge from 
#3 to #6 has been proposed, replacing #4 and #5.  Tooth #3 has an existing crown, and good bone 
support.  Tooth #6  has noted bone loss of the distal aspect in the range of 50%. There has been no 
documentation as to the periodontal condition of tooth #6 supplied, either with periodontal charting, mobility or 
proposed periodontal treatment. In general a tooth needs to have at least 50% of the supporting bone remaining 
to be usable as a support for a multi-unit prosthesis. This is due to the fact that the abutment tooth must not 
only support itself, but also part of the span of the bridge and missing teeth. Where it has not been clearly 
established that a periodontally involved tooth such as #6 has undergone periodontal treatment and has shown 
itself to be stable without mobility, a tooth with 50% or more loss of supporting bone would not be considered 
as a proper abutment for a bridge prosthesis. The long term prognosis of a bridge with a compromised 
abutment is much poorer than for one with abutments with adequate bone support, and therefore the requested 
bridge is not medically necessary. All subordinate services such as core buildup and pontics therefore are also 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D2950, D6752, D6242).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment testing provided on June 8, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment testing. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the ordered cardiac risk 
assessment testing is not covered testing for screening. 
 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 cardiac risk assessment testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the cardiovascular screening/risk assessment 
panel at issue in this case meets Medicare criteria for medically reasonable and necessary as the evidence 
confirms this was a screening service that was not medically necessary for the enrollee's care management. 
 
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 cardiac risk assessment testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the cardiac risk assessment testing provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen concentrator and portable gas for 12 months. 
 
You asked the Plan to pre-approve oxygen concentrator and portable gas for 12 months. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items 
are not medically necessary for 12-month use. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patient's skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator and portable gas 
for 12 months. Our reviewer says that the requested items are not medically necessary for 12-month use at this 
time. Our physician reviewer found you were tested during an exacerbation of chronic obstructive pulmonary 
disease (COPD), as documented in the practitioner note of May 19, 2022, when the SpO2 was 88% at rest on 
room air, and you were treated for an exacerbation. It is possible that you may no longer require oxygen after 
recovering from the exacerbation. You should be recertified for oxygen need during the next three months after 
recovering from the exacerbation. Therefore, you do not meet criteria for the requested 12-month use of 
oxygen supplies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen concentrator and portable gas for 12 months have not been met. 
Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator and portable gas for 12 
months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a tertiary-level radiation oncologist. 
 
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 tertiary level of care is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the treatment of the 
enrollee's sarcoma falls under the scope of general radiation oncology practice. There are consensus treatment 
guidelines for sarcomas, as well as practice-defining studies, from cooperative groups and large institutions. 
The enrollee wishes to receive tertiary care for personal reasons; however, there is no evidence that the tertiary 
level of care is reasonable or medically necessary at this time. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level radiation oncologist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the at home Covid-19 test purchased on January 21, 2022.
You asked the Plan to pay for this test. You say that this test should be covered by the Plan. The Plan denied
your request. The Plan says this test was not covered at the time of purchase. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. Medicare rules stated Plan were allowed to decide if they would cover home
COVID-19 test kits as a supplemental benefit. The Plans contract addendum states coverage for home test kits
began as of February 1, 2022. This test kit was purchased prior to the beginning of this benefit. Therefore, we
decided that the Plan does not have to pay for the at home Covid-19 test purchased on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 19, 2022.
You asked the Plan to pay for this test kit. You say that this test kit should be paid for by the Plan. The Plan
denied your request. The Plan says this test is covered by Original Medicare. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The
Plan states that a letter was sent to all enrollees indicating that coverage for up to 8 home tests would be
provided beginning on February 1, 2022. This purchase does not qualify for that benefit.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Plans were given the option
to cover home testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan
communicated to enrollees that this testing would be covered supplementally free of charge after February 1,
2022. You purchased this test on January 19, 2022, which is prior to the beginning of the benefit. Therefore, we
decided that the Plan does not have to pay for a home COVID-19 test purchased on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were told this would be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $195 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $195 copayment for CT scan. CT scan falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for CT scan provided on March 17, 2022.