Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).
You asked the Plan to pre-approve these services. You say that the prosthetic leg and components are medically necessary. The Plan denied your request. The Plan says that the provider describes no activities that cannot be met with a K3 mechanical knee, as you have been using.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856). Our Medical Director states that the case file does not contain clinical documentation that supports that an advanced microprocessor knee is medically reasonable and necessary for the enrollee in this case. There is insufficient clinical documentation of functional need for the technologic or design feature of the requested knee. Our Medical director reviewer found that your condition does not meet criteria for coverage of these services. 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 an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an interim implant component on tooth 
#3 and 5 (D6198), endosteal implants on tooth #3 and 5 (D6010), a bone graft on tooth #3 (D6104), and an 
unspecified implant procedure on tooth #3 and 5 (D6199). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary after 
experiencing a fractured root canal. The Plan denied your request. The Plan says the requested services are not 
covered by your supplemental dental 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 pre-approve the 
removal of an interim implant component on tooth #3 and 5 (D6198), endosteal implants on tooth #3 and 5 
(D6010), a bone graft on tooth #3 (D6104), and an unspecified implant procedure on tooth #3 and 5 (D6199).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 6, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that this claim was submitted correctly. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration (D4266). You say that you were not told that 
the service was not covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration (D4266) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve the guided tissue regeneration (D4266).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 186 one-way prorated miles in connection with medically 
necessary laboratory specimen collection drawn from home bound or nursing home bound patient (P9603) 
billed for date of service March 29, 2022. 
 You asked the Plan to pay for miles in connection with laboratory specimen collection. You say that these 
services are supported as billed. The Plan denied your request. The Plan says the medical records do not 
support this service as billed. 
 
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 miles in connection with laboratory 
specimen collection have been met. Specifically, no records or documentation were provided to support the 
service at issue. Therefore, we decided that the Plan does not have to pay for 186 one-way prorated miles in 
connection with medically necessary laboratory specimen collection drawn from home bound or nursing home 
bound patient (P9603) billed for date of service March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that the enrollee received a partial in 
2022 at another location. You also say that the enrollee is unhappy with it because it is ill-fitting. 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 June 2, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed
incorrectly.

The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the
appropriate claim information must be submitted.

We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX ZCode as required by LCA A56853. 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 genetic testing
provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of endosteal implants (D6010 
x10). 
 
You asked the Plan to pre-approve the surgical placement of endosteal implants (D6010 x10). You say that 
since the surgery is medically necessary, these services would be run under your medical benefits. The Plan 
denied your request. The Plan says the services are not covered under your medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under your medical benefits. Please note, you are eligible for coverage up to the 
allowable $1,000 per calendar year under your dental benefits. Therefore, we decided that the Plan does not 
have to pre-approve the surgical placement of endosteal implants (D6010 x10).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tibsovo.

You asked the Plan to pre-approve Tibsovo. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Tibsovo.

Benefits for Tibsovo may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
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 June 3, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should not be considered 
bundled. 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 June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 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 procedure code 87500 is not supported. 
 
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 87500 is infectious agent detection by nucleic acid (DNA 
or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT code 87500 is not supported in the medical record. Specifically, there is no documentation of 
infectious agent detection by nucleic acid for vancomycin resistance, amplified probe technique. 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 pay for the laboratory services rendered on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (cutting procedure) 
(D7250), deep sedation/general anesthesia-first 15 minutes and deep sedation/general anesthesia, each 
subsequent 15-mintues increments (D9223). 
 
You asked the Plan to pre-approve dental services. You say that previously you had a tooth extracted and the 
remaining roots could not be removed. Now you are having issues with your dentures. The Plan denied your 
request. The Plan says this service is not covered under your 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. Removal of residual tooth 
roots (cutting procedure) (D7250) is not covered under the Plans dental benefits. 
 
  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. Deep sedation/general anesthesia-first 15 minutes and deep 
sedation/general anesthesia, each subsequent 15-mintues increments (D9223) is covered under the Plan only 
when provided with covered services. Therefore, we decided that the Plan does not have to pre-approve 
removal of residual tooth roots (cutting procedure) (D7250), deep sedation/general anesthesia-first 15 minutes 
and deep sedation/general anesthesia, each subsequent 15-mintues increments (D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care billed to the enrollee for November 11, 2021, to November 19, 2021.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the 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 information and the billing issue.
The Plan noted that the claim submitted with an inpatient admission date of November 15, 2021. However, the medical records state the decision to admit was made by the emergency department on November 11, 2021. The Plan states 8 units or a value of 80 was billed, which would not support the claims stated admission date of November 15, 2021.
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, this claim could not be paid as billed due to a discrepancy on the claim with the actual date and time of admission. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care billed to the enrollee for November 11, 2021, to November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473).. You say that you are losing 
weight because you are unable to chew and not eat very much. You say the removal of torus mandibularis 
needs to be done. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of torus mandibularis 
(D7473) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the removal of torus mandibularis (D7473).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH
admission criteria, and you believe that a this would be the best option for their care. The Plan denied your
request. The Plan says the enrollee's medical needs are being met in the current acute setting and an LTACH
would add no additional services.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there are no services available at the LTACH that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the condition of the enrollee. LTACH services are not able to be furnished
safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87651 an additional unit of code 87481 billed on 
December 27, 2021. 
 
You asked the Plan to pay for code 87651 an additional unit of code 87481. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these codes are not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that providers must report the 
actual number of units provided for each procedure code.  
In this case, the CPT Code Manual definition of code 87651 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, amplified probe technique. This testing is not documented in the submitted 
records. We also find that an additional unit of CPT code 87481 is not supported in the medical record. The 
medical record only supports 2 units of CPT code 87481. Based on this information, we decided that Medicare 
rules for coverage of code 87651 an additional unit of code 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for code 87651 an additional unit of code 87481 billed on December 27, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option (K0835) with power tilt (E1002) and attachments.
You asked the Plan to pre-approve a Group 2 power wheelchair with single power option (K0835) with power tilt (E1002) and attachments. You say that the this is medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met with a group 2 power wheelchair with no power option.
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 a Group 2 power wheelchair with single power option (K0835) with power tilt (E1002) and attachments. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The single power option of a power tilt is not medically necessary as the provider team documents Roho cushion is providing necessary pressure relief and there are no other documented reasons for power tilt being necessary. Our physician reviewer found that your condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 2 power wheelchair with single power option (K0835) with power tilt (E1002) and attachments have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option (K0835) with power tilt (E1002) and attachments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the 
adolescent dentition (D8080). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment of the adolescent dentition 
(D8080). You say that the enrollee has a debilitating malocclusion and requires mandibular braces or invisalign 
to close spaces and consolidates the mandibular teeth to prevent tooth loss. The Plan denied your request. The 
Plan says this service is not covered under the 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 a 
comprehensive orthodontic treatment of the adolescent dentition (D8080).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 13, 2021, 
through September 30, 2021. 
 You asked the Plan to pay for the home health services provided. You say that the other dates were billed to 
Medicare, but you believe that this set of dates should be paid by the Plan. The Plan denied your request. The 
Plan says Original Medicare remains responsible for these services until the end of the month in which hospice 
is revoked. 
 
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 September 10, 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 home health 
services provided from September 13, 2021, through September 30, 2021.