Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 9, 2021. You asked the Plan to pay for the eye refraction. You say that this service is a covered benefit, and you should 
be reimbursed for this care. The Plan denied your request. The Plan says the eye exam in this case was 
provided for medical purposes. Refractions are not covered in conjunction with medical (non-routine) vision 
care. 
 
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 these services when it is received from a provider who participates in the Plans 
routine vision vendor network as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The claim indicates that the eye exam in this case was provided for 
evaluation of glaucoma, which is a medical purpose and means that the eye exam in this case is not a routine 
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 November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service December 9, 
2021. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service December 9, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 
23, 2021. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service December 23, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on April 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was a necessary tool when determining 
treatment for the enrollee. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transluminal balloon angioplasty (37246) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the transluminal balloon angioplasty. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
does not support the service billed. 
 
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 37246 is transluminal balloon angioplasty (except lower 
extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or 
percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the 
angioplasty within the same artery; initial artery. We asked our coder 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 transluminal balloon angioplasty. Our reviewer says that 
CPT code 37246 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
operative report describes a thrombectomy with a Treratola Thrombectomy Device. Therefore, documentation 
does not support a transluminal balloon angioplasty. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transluminal balloon angioplasty have not been met. Therefore, we decided 
that the Plan does not have to pay for the transluminal balloon angioplasty (37246) provided on September 29, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage of the SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have any parenteral 
medication; complex wound care or nutrition given via a feeding tube.  You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you 
can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the 
lower extremity. 
 
You asked the Plan to pre-approve an MRI of any joint of the lower extremity. You say that the services are 
necessary. The Plan denied your request. The Plan says the appeal was received after the enrollee's plan 
termination date. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a plan is legally responsible under its contract 
and the regulations to authorize, provide, or pay for all Medicare covered services or prescription drugs that are 
denied and upon appeal are found to be services the plan should have authorized, provided, or paid for its 
enrollees. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an MRI of any joint of the lower extremity have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the lower extremity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 14, 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 a duplicate submission. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plans provided documentation to show the
services billed under Claim A had already paid for this service under Claim B.
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 codes. In this case the Plan
provided documentation to show these services were previously paid. Therefore, we decided that the Plan does
not have to pay for physician services provided to the enrollee on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical steroid injections.
You asked the Plan to pre-approve this treatment. You say that at the time of the appeal, this treatment was
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 criteria or injection location.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for repeat cervical
epidural steroid injection. The Maximus Physician Reviewer determined that repeat cervical injection was
considered medically reasonable and necessary in this case. The reviewer found that the enrollee had
documented cervical spinal stenosis at multiple levels. The request for repeat injections was determined to be
medically reasonable and necessary. However, the Maximus letter states the request was for lumbar epidural
injections. The Plan requested a reopen and indicated the IRE was incorrect regarding the location for the
epidural injections.
The Plan is correct in the case. The medical records show in an electrophysiologic findings for August 30,
2021, there was "No findings of a cervical radiculopathy in either upper extremity". An MRI of the neck
showed multi-level degenerative changes with disc osteophyte complexes and narrowing. On September 30,
2021, the enrollee reported a positive response to an initial cervical epidural steroid injection that was
performed on August 10, 202.
The Medicare LCD L35457 (Nerve Blockade for Treatment of Chronic Pain and Neuropathy) states that
steroids should be used only in the presence of radiculopathy. The documentation in the case file does not
support that the coverage criteria for cervical epidural steroid injection were met in this case, as the enrollee
does not have radiculopathy. 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 pre-approve cervical steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that you suffer from carbon dioxide retention and 
need this ventilator because no other device is able to reduce the carbon dioxide levels sufficiently. The Plan 
denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not considered medically necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic respiratory failure with hypercarbia from chronic obstructive pulmonary 
disease. The record indicates that the ordered settings are bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS).  The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS 
capability. The plan has indicated such a device is covered. The elements of the coverage criteria are not 
satisfied. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite, one surface, on tooth #11 
(D2330), a resin-based composite, three surfaces, on tooth #9 (D2332), a crown on tooth #6 (D2740), a 
prefabricated post and core in addition to a crown on tooth #6 (D2954), endodontic therapy on tooth #6 
(D3310), an upper partial denture (D5213) and a tooth extraction on tooth #22 and tooth #15 (D7210). 
 
You asked the Plan to pre-approve dental services. You say that you are no longer able to eat. You also say that 
if you would have known that the dentures were going to be denied, you would have never gotten your teeth 
pulled. The Plan denied your request. The Plan says you have exhausted your maximum benefit for teeth 
extractions and fillings. The Plan also says that any procedure code not listed is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and Medicare rules. The records show that you received two fillings and three teeth extractions on March 4, 2022; therefore, you have exhausted your maximum benefit for those services. The records also show that a crown, a prefabricated post and core, endodontic therapy, and an upper partial denture are not covered benefits with your Plan. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a resin-based composite, one surface, on tooth #11 (D2330), a resin-based composite, three surfaces, 
on tooth #9 (D2332), a crown on tooth #6 (D2740), a prefabricated post and core in addition to a crown on 
tooth #6 (D2954), endodontic therapy on tooth #6 (D3310), an upper partial denture (D5213) and a tooth 
extraction on tooth #22 and tooth #15 (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 23, 24, 25, and 26 and 
retainer crowns (D6750) for tooth #'s 21, 22, and 27. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan 
says the x-rays your dentist sent us show you are missing other teeth and are requesting a 7-unit bridge. The 
Plan also says that these services do not meet criteria for medical necessity. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontics and retainer crowns. Our 
reviewer says that the criteria for coverage are not met. Our physician reviewer found in this instance the 
request has been made for a seven-unit bridge spanning from tooth #21 to #27. Our reviewer found that the 
requested bridge is in excess of the four units maximum length bridge (two pontics and two abutments), with 
four lower teeth being replaced. Our physician reviewer also found that given the Plan coverage limitations 
there would be no necessity for the seven-unit bridge being requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 23, 24, 25, and 26 and retainer crowns 
(D6750) for tooth #'s 21, 22, and 27.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for coverage of the requested SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the member does not have any parenteral 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 11, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that when you asked about 
your cost or share for this service, you were told it should be covered by the Plan. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on February 1, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, expandable controller, 
including all related electronics and mounting hardware, upgrade provided at initial issue (E2377) power 
wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (E2313) power wheelchair accessory, electronic connection between wheelchair controller 
and two or more power seating system (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please reconsider the documentation 
provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. 
The Plan denied your request. The Plan says the approved power options come with their own switches. There 
is no 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 based on the medical records provided there is no documentation that supports the 
medical necessity of the requested power wheelchair accessories as defined by Medicare criteria. Provided 
records document that the enrollee has 3+/5 right upper extremity strength and is independent with feeding and 
grooming thus indicating he has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. 
 
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 power wheelchair accessory, expandable controller, including all related 
electronics and mounting hardware, upgrade provided at initial issue (E2377) power wheelchair accessory, 
harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware 
(E2313) power wheelchair accessory, electronic connection between wheelchair controller and two or more 
power seating system (E2311).