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

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the procedure was 
performed. The Plan denied your request. The Plan says that the code has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. The claim shows that code 76641 was billed with 2 units on individual claim lines using modifiers 
LT and RT as required. Based on this information, we decided that Medicare rules for coverage of the billed 
services have been met. Therefore, we decided that the Plan has to pay for procedure code 76641 billed for date 
of service September 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic crown (D2740) for tooth number 13, 
and core buildup (D2950) for tooth number 13. 
 
You asked the Plan to pre-approve the dental services. You say that this service has only been completed one 
time on tooth number 13. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The Plan 
rules show that there is one porcelain/ceramic crown (D2740) for tooth number 13, and core buildup (D2950) 
for tooth number 13 allowed per tooth. The record shows your benefit for the requested item or service has 
previously been exhausted. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic 
crown (D2740) for tooth number 13, and core buildup (D2950) for tooth number 13.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees medical management and rehab needs 
require an inpatient rehab stay and close physician supervision. The Plan denied your request. The Plan says 
the request is not medically necessary, the services the enrollee needs can be provided safely in other settings, 
for example, a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you had an accident and broke your 
dentures. You also feel that you should not have to eat blended food for the remaining time. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 23, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a 
complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377) harness for 
expandable controller (E2313) electronic connection between wheelchair controller and two or more power 
seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the records provided support the 
necessity of the requested service. 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. 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee has a neurologic disorder with functional deficits. The 
criteria for a power wheelchair are met. The requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller (E2377) harness for expandable controller (E2313) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing determines underlying pathogenesis of 
pain. The Plan denied your request. The Plan says medical necessity is unable to be determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the treating 
physician to show the test was ordered for a specific problem. This testing is not covered for screening 
services. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing provided to the enrollee on February 14, 2022.
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the panel is not the same as the date the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing provided to the enrollee on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee acrylic socket. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the socket 
is not reasonable and necessary. 
 
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 file shows that a preparatory below knee prosthesis, L5540, was 
previously approved by the Plan. When this prosthesis is provided, code L5629 is not considered reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a below knee acrylic socket.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the unspecified adjunctive procedures (D9999) provided on January 13, 2021, prophylaxis (D1110) provided on April 22, 2021, and an unspecified adjunctive procedure (D9999), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 26, 2021.
You asked the Plan to provide additional payment for the dental services. You say that you disagree with the denials of these dental services. The Plan denied your request. The Plan says that your annual limit for dental services has been exhausted.
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 pays up to $750 every year for non-Medicare covered preventative dental services and non-Medicare covered comprehensive dental services combined. We looked at the file and Plan rules. The file shows that the plan has approved the maximum yearly benefit of $750 for dental services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to provide additional payment for the unspecified adjunctive procedures (D9999) provided on January 13, 2021, prophylaxis (D1110) provided on April 22, 2021, and an unspecified adjunctive procedure (D9999), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for a specialist visit provided on May 21, 2022.
You asked the Plan to waive this copayment. You say that you only went to this office for a COVID-19 test. You were under the impression this would be no charge. The Plan denied your request. The Plan says this cost sharing was charged correctly based on the claim submitted by your provider. Maximus overturned the Plans denial because the case file lacked the correct Plan contract. The Plan requested a reopen and provided the required Plan contract.
The Plan is correct in this case The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $45 copayment for each specialist office visit.
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 $45 copayment charged for a specialist visit provided on May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 (sales tax) billed for date of service 
July 6, 2022. 
 
You asked the Plan to pay for procedure code S9999. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
  
We find that procedure code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9999 (sales tax) billed for date of service July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), a mandibular 
partial denture (D5214), and an extraction of an erupted tooth (D7210) for teeth numbers 2, 3, 13, 14, 15, 18, 
and 31. 
 
You asked the Plan to pre-approve a maxillary partial denture (D5213), a mandibular partial denture (D5214), 
and an extraction of an erupted tooth (D7210) for teeth numbers 2, 3, 13, 14, 15, 18, and 31. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says there is no coverage for the 
dentures. The Plan also says that you already requested the allowed frequency of extractions of erupted teeth or 
exposed roots (D7140) on the appeal form.  
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 rules show that a 
maxillary partial denture (D5213), and a mandibular partial denture (D5214) are not among those covered 
under this benefit. The Plan rules also show that they only cover two extraction procedure codes per calendar 
year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a maxillary partial denture (D5213), 
and a mandibular partial denture (D5214) are not among those covered under this benefit. The Plan rules also 
say that they only cover two extraction procedure codes per calendar year. This benefit was exhausted with this 
pre-approval. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213), a mandibular partial denture (D5214), and an extraction of an erupted tooth (D7210) for teeth 
numbers 2, 3, 13, 14, 15, 18, and 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921 x 4) provided on 
September 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these dental services are 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 services provided are not among 
those covered under this benefit. Additionally, these services were rendered by an out-of-network provider. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921 x 4) 
provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reimburse more of the charges for the office visit.

You asked the Plan to reimburse more of the charges for the office visit.. You say that you paid $182.29 out-of-pocket for your physician visit and the Plan was supposed to reimburse $174.86 but sent a check for $7.43 instead. The Plan denied your request. The Plan says that they were not able to come to a decision within the timeframe.

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. The Plan did not submit information explaining why only a partial payment was made and not the full reimbursement amount. The contract rules state the enrollee is only required to pay a $5 copayment for a primary care or specialist visit. Therefore, we decided that the Plan has to reimburse more of the charges for the office visit. 

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 a power seat lift and lap belt. 
 
You asked the Plan to pre-approve a power seat lift and lap belt. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are specifically not 
covered. The rules say that Medicare covers DME only when it is reasonable and necessary. If DME serves the 
same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
 We looked at the file and Medicare rules. The requested seat elevation system is not covered. The requested lap 
belt is included in the new power wheelchair. This means this item cannot be separately billed. Based on this 
information, we decided that Medicare rules for coverage of a power seat lift and lap belt have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat lift and lap belt.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper right, the 
lower right, the upper left, and the lower left quadrant. 
 
You asked the Plan to pre-approve gingival irrigation (D4921) for the upper right, the lower right, the upper 
left, and the lower left quadrant. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this service is not covered under the member's benefit package. 
 
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 
gingival irrigation (D4921) for the upper right, the lower right, the upper left, and the lower left quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing (D4341) for the
upper right, upper left, lower right, and lower left quadrant.

You asked the Plan to pre-approve a periodontal scaling and root planing (D4341) for the upper right, upper
left, lower right, and lower left quadrant. You say that you are requesting an appeal for the denial of dental
services as the member has bone loss evident in the records. The Plan denied your request. The Plan says this is
not medically necessary.

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 a periodontal
scaling and root planing (D4341) for the upper right, upper left, lower right, and lower left quadrant 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 a periodontal scaling and root planing
(D4341) for the upper right, upper left, lower right, and lower left quadrant. Our reviewer says that this service
is not medically necessary. Our physician reviewer found there are three or less teeth in each quadrant showing
loss of bone. Therefore, the criteria for this service has not been met.

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 a periodontal scaling and root planing (D4341) for the upper right, upper left,
lower right, and lower left quadrant have not been met. Therefore, we decided that the Plan does not have to
pre-approve a periodontal scaling and root planing (D4341) for the upper right, upper left, lower right, and
lower left quadrant
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation.

You asked the Plan to pre-approve the additional non-emergency transportation. The Plan denied your request.
The Plan says your plan benefits for this service is exhausted. Our records indicate you received 12 trips from
March 31, 2022 to November 9, 2022.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 12 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation.