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

We decided that the Plan has to provide coverage for an oral splint mouthguard.
You asked the Plan to provide coverage for this item. You say that this oral splint mouthguard is medically
necessary. The Plan denied your request. The Plan says that the splint is not ordered for a covered medical
condition. Maximus overturned the Plans denial. The Plan requested a reopen and stated that based on Chapter
15 of the Medicare Benefit Policy Manual, "Dental splints used to treat a dental condition are excluded from
coverage under 1862(a)(12) of the Act."
However, review of Chapter 15 of the Medicare Benefit Policy manual section 150 reads as follows:
"Dental splints used to treat a dental condition are excluded from coverage under 1862(a)(12) of the Act. On
the other hand, if the treatment is determined to be a covered medical condition (i.e., dislocated
upper/lower jaw joints), then the splint can be covered."
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome when
the condition or symptom is medical in nature. The rules also state for dental splints, if the treatment is
determined to be a covered medical condition, then the splint can be covered. Our physician reviewer found
this was an oral splint (mouthguard) requested to treat bruxism causing TMJ pain. The main etiology of
bruxism is stress. The medical records show you have a diagnosis of post-traumatic stress disorder (PTSD).
This dental splint is being used to treat a medical condition (PTSD) and to alleviate pain associated with TMJ
disorder. Therefore, the documentation meets the criteria that the treatment of the TMJ pain is the result of a
medical condition (PTSD).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this item have been met. Therefore, we decided that the Plan has to provide
coverage for an oral splint mouthguard.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for sclerotherapy for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for right lower
extremity visual sclerotherapy. The Maximus Physician Reviewer determined that the requested sclerotherapy
was medically necessary. The Plan requested a reopen and argues that the LCD indicates that there must be
evidence of reflux in the veins for an invasive procedure to be covered. The Medical records show the enrollee
is a 75-year-old woman with right lower extremity symptomatic varicose and spider veins. A lower extremity
venous ultrasound on July 16, 2021, revealed no evidence of deep vein thrombosis or reflux in the bilateral
lower extremity veins. The Plan is correct in this case. LCD L34924 states that invasive procedures for the
treatment of varicose veins are considered medically reasonable and necessary when all of the criteria are met,
including "A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers
in the saphenous, or perforator veins is 500 milliseconds or greater and absence of deep venous obstruction..."
The presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous, or perforator
veins has not been demonstrated by ultrasound in this case. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this treatment have not been met. Therefore, we decided that the Plan does not
have to provide coverage for sclerotherapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology visit provided on April 11, 
2022. 
 
You asked the Plan to waive the copayment for a dermatology visit. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $45 
copayment for physician/practitioner services, specialist consultation.  
 
You have been asked to pay a $45 copayment for a dermatology visit. A dermatology visit falls within the 
Physician/Practitioner Services, Specialist Consultation 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 a dermatology visit provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided on October 22, 2021.
You asked the Plan to pay for these services. You say that you believe the dental services should be covered by the Plan. The Plan denied your request. The Plan says the annual maximum benefit of $1500 had been exceeded. The Plan also says that deep sedation services are not listed as covered. Maximus partially overturned the Plans denial for lack of documentation to show the $1500 maximum had been exhausted. The Plan requested a reopen and provided documentation to show this benefit had indeed been exhausted.
The Plan is correct in this case. 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 more than Medicare coverage, sedation services are not covered, and the $1500 maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay any of the dental services provided on October 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit, optic nerve 
imaging, and visual field examination on January 31, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit, optic nerve imaging, and visual field 
examination. You say that you should not be responsible for this copayment The Plan denied your request. The 
Plan says the cost share has been applied correctly. 
 
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 a $43 
copayment for services received from an in-network specialist. However, you have only been asked to pay $11, 
which is less than the $43 copayment amount. Your contract with the Plan also clearly says that you must pay a 
$75 copayment for diagnostic procedures and tests, including ultrasounds. However, you have only been asked 
to pay $64, which is less than the $75 contract amount. 
 You have been asked to pay a $75 copayment for a specialist office visit, optic nerve imaging, and visual field 
examination. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visits benefit category. Optic nerve imaging and visual field examinations fall 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 a specialist office visit, optic nerve imaging, and visual field examination on January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018-26 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 74018-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 74018-26 is bundled into 
payment for code 74250-26. 
 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, we have confirmed that code 
74018-26 is a column II code to column I code 74250-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 74018-26 billed for date of service 
March 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this could should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for total knee replacement for the enrollee.
You asked the Plan to provide coverage for inpatient admission. You say that at the time of the appeal, inpatient admission was medically necessary for knee replacement. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient hospital services for an enrollee undergoing total knee arthroplasty. The Maximus Physician Reviewer determined that the enrollee had significant co-morbidities that would place her at increased risk for peri-surgical complications requiring an inpatient stay.
The Plan requested a reopen and argues the medical records did not clearly outline why 2 midnights would be appropriate for the enrollee. The medical records show the enrollee is a 59-year-old woman with a medical history that includes stroke, diabetes, hypertension, sleep apnea, and anemia. A robotic assisted total knee arthroplasty on the right was planned. A preoperative risk evaluation was performed on January 26, 022 and the enrollee was considered intermediate risk for surgery. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that at the time of the inpatient admission it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient admission for total knee replacement for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up computed tomography (CT) scan (76830) and moderate sedation services (99152 and 99153) provided on August 17, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional claim information. The Plan says these codes were denied because a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 772990, 99152 and 99153. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers allowed with this PTP code pair.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the codes in question cannot be billed separately based on the Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for the follow-up computed tomography (CT) scan (76830) and moderate sedation services (99152 and 99153) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual wellness visit (G0439) provided on February 21, 2022. 
 
You asked the Plan to pay for the annual wellness visit (AWV). You say that this is a covered service. You also 
say that you were billed erroneously. The Plan denied your request. The Plan says that this is not a covered 
service. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, there is no documentation provided to show that you received an AWV within 12 
months to the visit at issue in this case. Therefore, we decided that the Plan has to pay for the annual wellness 
visit (G0439) provided on February 21, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 28, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you had an emergency situation. You say 
that you were treated at your primary doctor's office for a panic attack. You say that an ambulance was called 
in case you needed further testing at the hospital. You also say that you were not informed that the charges 
would not be covered since you were not transported to the hospital. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 28, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine 
transportation is necessary for your condition. The Plan denied your request. The Plan says the benefit for 
routine transportation has been exhausted. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way 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 routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole caplet 40mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole caplet 40mg 
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service January 31, 
2021. 
 
You asked the Plan to pay for procedure code 99284. You say that the enrollee was seen by the emergency 
room physician for a medically necessary procedure and the claim should be reprocessed to pay this procedure 
code. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair. 
  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, we have confirmed that code 99284 
is a column II code to column I code 99220 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99284 billed for date of service January 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital admission provided from March 29, 
2022, to March 31, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the admission was deemed 
medically necessary in the enrollee's best interest until March 31, 2022. The Plan denied your request. The Plan 
says these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the presentation and initial workup, it was not expected that this 
enrollee would have required hospital care that would likely have crossed 2 midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient hospital admission provided from March 29, 2022, to March 31, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not billed correctly. 
 
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 states that the claim was not billed with the required DEX-Z code, per 
Local Coverage Determination (LCD) L35025; however, this LCD is not valid for the state of Massachusetts 
where the testing is performed. The Plan has not provided any documentation or Medicare rules to support that 
the testing is not covered. Therefore, we decided that the Plan has to pay for the FANCC genetic testing 
rendered on February 11, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no supporting documentation to verify progressive functional improvement 
towards treatment goals. 
 
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 the 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 enrollee has responded to the exercise program, and is able to continue 
with a repetitive exercise program shown to be effective. The enrollee does not require the skills from a 
therapist to continue this program of rehabilitation. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve eight physical therapy visits for the enrollee.