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

We decided that the Plan does not have to pay for medical services provided on April 2, 2021.
You asked the Plan to pay for these services. You say that this bill should be covered by the Plan. The Plan
denied your request. The Plan says the emergency facility used is not a Medicare eligible facility. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria. The Plan says that Medicare put out guidance for licensed independent freestanding emergency
departments (EDs) to participate in Medicare and Medicaid during the COVID-19 Public Health Emergency.
Providers are required to enroll in this program to allow billing of services to Medicare. The provider you were
treated by did not enroll in this program.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not pay for services
provided by free standing emergency facilities that are not affiliated with a hospital. These facilities were
provided an opportunity to enroll in an exception program due to COVID-19. This provider is not affiliated
with a hospital and is not part of the exception program. Therefore, we decided that the Plan does not have to
pay for medical services provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
September 9, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you would like this claim to be 
reconsidered for coverage because you do not have a lot of income. The Plan denied your request. The Plan 
says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431) provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and extraction. You say that you were advised to see an 
oral surgeon to have your tooth extracted. The Plan denied your request. The Plan says dental services must be 
performed by a participating general dentist. The Plan also says that dental services performed by an oral 
surgeon are not covered. 
 
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 
covered when they are provided by anyone other than a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a benign tumor and bone graft (21047,
21215) provided on May 25, 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 this claim was previously paid. Maximus overturned the Plans denial as documentation
was not provided to show when payment was made. The Plan requested a reopen and provided additional
information. The Plan provided documentation to show these services were billed with modifier 62 indicating
that two surgeons worked together as primary surgeons. The claim history indicates that global payment for
these codes has already been processed. The history shows that another provider billed as the solo surgeon for
these services on the billed date of service. Since the services have already been reimbursed to the other
provider payment would not be appropriate in this situation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case the documentation shows these services were already processed and paid.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the excision of a benign tumor and bone graft (21047, 21215) provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for chest x-ray services provided on November 15, 2020.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says these services were previously paid. Maximus overturned the
Plans denial. The Plan requested a reopen and provided documentation to show a claim for these services was
previously submitted and paid.
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, review of claim
history shows two units of code 71045 was previously billed and paid by the Plan. The documentation shows 1
unit of code 71045-26 was billed and paid on December 09, 2020, and 1 unit of code 71045-26-76 was billed
and paid on December 10, 2020. Therefore, we decided that the Plan does not have to pay for chest x-ray
services provided on November 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on December 17, 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 Medicare billing criteria were not met due to a modifier issue. Maximus overturned
the Plans denial for insufficient billing regulations to support their denial. The Plan requested a reopen and
provided additional billing information. The Plan states that per the National Correct Coding Initiatives
(NCCI), a Procedure to Procedure (PTP) edit exists between codes 36556 and 99222. This PTP edit has a
modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate
NCCI modifier was not billed with this PTP code edit.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. The Plan provided documentation from the 2020 American Medical Association
Column 1/Column 2 Edits page to show that code 99222 has a status code of "1" indicating a modifier would
be allowed and/or required in some instances. In this case an appropriate modifier was not listed with this code
pair. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for physician services provided on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) 
provided on January 26, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images, comprehensive oral evaluation, and 
complete series of intraoral x-rays. You say that on the member portal it shows your effective date for dental 
coverage is January 1, 2022. You also say that when you went to the dentist, they told you your effective date 
was February 1, 2022, which is incorrect. The Plan denied your request. The Plan says the 2D oral/facial 
photographic images are not a covered benefit under your dental plan. The Plan also says that the 
comprehensive oral evaluation and complete series of intraoral x-rays exceed the frequency limitations in your 
benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on August 14, 2020 and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4), comprehensive oral 
evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drainage of abscess, cyst, hematoma from dentoalveolar 
structures (41800) provided January 5, 2022. 
 
You asked the Plan to pay for the drainage of gum lesion. You say that you feel this should be covered under 
your medical benefits. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
drainage of abscess, cyst, hematoma from dentoalveolar structures (41800) provided January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards (K0108) for a manual wheelchair. 
 
You asked the Plan to pre-approve side guards. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve side guards (K0108) for a manual wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis. 
 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established as the next step in evaluation of chronic 
lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found duplex ultrasound of the 
lower extremity deep veins was negative on 3/30/22. Importantly, the deep pelvic veins are not seen on this 
study, and evaluation for pelvis venous clots as well as lymphadenopathy causing venous congestion is 
necessary. CT abdomen and pelvis is the next procedure of choice and should be approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the abdomen and pelvis. 
  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 8, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 8, 2021 have been met. The Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested hospital bed is not medically necessary. Our physician reviewer found the 
provided documentation describes the patient being able to move himself around in bed without assistance, no 
choking risk, no bed sores requiring frequent repositioning, and no need for traction to support this bed or any 
other attachments. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 25, 2022. 
 You asked the Plan to pay for the eye refraction. You say that this service should be covered. The Plan denied 
your request. The Plan says eye refractions are only covered when performed by a provider who is part of the 
Plan's specified routine hearing vendor network as part of a routine eye exam. The eye refraction in this case 
was billed as part of a 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions when they are performed by a provider in the Plans specified routine 
vision network as part of a routine (non-medical) eye exam. 
 
We looked at the file and the Plan's rules. The refraction in this case was provided as part of a medical eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
the Botox is medically reasonable and necessary for the enrollee. The documentation does not support that the 
Botox is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for open procedures involving upper two-
thirds of femur (01230) provided on November 12, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the service is unrelated to the enrollee's terminal 
condition. You say there is no evidence that the enrollee was enrolled with hospice for this date of service. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 11, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for 
open procedures involving upper two-thirds of femur (01230) provided on November 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the services. You say that you need to keep up with the heart rate, they 
check it to adjust the medicine according. The Plan denied your request. The Plan says your request is not 
medically necessary because your records show there is not a question as to whether or not you have atrial 
fibrillation. The Plan states your doctor does not indicate that the replacement Loop monitoring test results 
would impact your medical management. 
 
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 physician reviewer 
found there is insufficient clinical evidence to support the medical appropriateness and necessity of replacing 
your old implantable loop recorder (ILR) with a new ILR. 
 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on September 29, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the CPT code at issue is inclusive to another billed code. 
 
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 a computed tomography (CT) scan of the head or brain (70450) 
provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus surgery, represented by Current Procedural 
Terminology (CPT) codes 31267 and 31259 for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says an incorrect code was requested, and there is a more appropriate code to use in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation in the case file does not support that CPT 31267 - Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus, and CPT 31259 - Nasal/sinus 
endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with 
removal of tissue from the sphenoid sinus are the most appropriate CPT codes for the planned nasal endoscopy 
under anesthesia with placement of a nasal septal button. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sinus surgery, represented by Current Procedural Terminology (CPT) codes 31267 and 
31259 for the enrollee.