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

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310) and fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve alveoloplasty and fixed partial denture sectioning. You say that you would 
like these services covered. The Plan denied your request. The Plan says these services are 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 pre-approve 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) and 
fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three prefabricated abutments (D6056 x3) and three 
abutment supported porcelain/ceramic crowns (D6058 x3), or pay more for the crown (D2750) provided on 
February 3, 2022. 
 
You asked the Plan to pay for the prefabricated abutments and abutment supported porcelain/ceramic crowns, 
and to pay more for the crown. You say that you feel these services should be covered. The Plan denied your 
request. The Plan says abutment supported porcelain/ceramic crown is not a covered service. The Plan also 
says that benefits have been paid on the least costly method of treatment, and you are responsible for the 
difference between the allowed amounts. 
 
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, the prefabricated abutment (D6056) 
and abutment supported porcelain/ceramic crown (D6058) are not among those covered under this benefit. The 
contract says that if the Plan determines that a less expensive alternate procedure, service, or course of 
treatment can be performed in place of a proposed treatment, then the maximum the Plan will allow will be the 
charge for the less expensive treatment. You are responsible for a 50% coinsurance for the crown plus the 
difference between the allowed amounts. Therefore, we decided that the Plan does not have to pay for the three 
prefabricated abutments (D6056 x3) and three abutment supported porcelain/ceramic crowns (D6058 x3), or 
pay more for the crown (D2750) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning you received from an out-of-network 
dentist on February 28, 2022. 
 
You asked the Plan to pay for the out-of-network dental cleaning. You say that you were not told that this 
dentist was not in your network. The Plan denied your request. The Plan says out-of-network dental services 
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 among those 
covered under this benefit. Out-of-network dental services are not covered for any reason. Therefore, we 
decided that the Plan does not have to pay for the dental cleaning you received from an out-of-network dentist 
on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 23, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that the medical records submitted support the 
billing of this claim. The Plan denied your request. The Plan says code 99053 is 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 CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed for date of service August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular denture (D5110 and 
D5120), provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a maxillary and mandibular denture. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the requested dental services 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary and mandibular denture (D5110 and D5120), provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (99213-95) billed to the enrollee for
September 2, 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 the records show this was an in person visit, yet the 95 modifier was used with is for
telehealth services. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not interpret the Plans denial correctly.
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. This was an in person visit
that the provider billed with a telehealth 95 modifier. The claim was billing incorrectly. Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
office visit services (99213-95) billed to the enrollee for September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen handling (99000) provided on January 2, 2022, 
and January 5, 2022. 
 
You asked the Plan to pay for specimen handling (99000). You say that you were informed you could go to any 
urgent care, and it would be covered. You say that the claims totaling $420 should be reimbursed. The Plan 
denied your request. The Plan says the office visits (99202), COVID-19 tests (87426) have been overturned. 
The Plan also says that the specimen handling (99000) remains denied as bundled services are not eligible for 
separate reimbursement. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of specimen handling (99000) have not been met. Therefore, we decided that the Plan does not have to pay for 
the specimen handling (99000) provided on January 2, 2022, and January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0272), prophylaxis (D1110), 
and resin-based composite (D2393) provided on February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, 
prophylaxis and resin-based composite. You say that you went to an OON provider because the in-network 
provider refused to let you visit. The Plan denied your request. The Plan says you self-referred to an OON 
dental provider. The Plan also says that you were advised by a customer service representative that your 
contract only covers services rendered by in-network providers except for emergent services. 
 
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 received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), 
bitewing x-rays (D0272), prophylaxis (D1110), and resin-based composite (D2393) provided on February 28, 
2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110). 
 
You asked the Plan to pre-approve an implant /abutment supported removable denture. You say that this 
service is medically necessary for your oral, physical and emotional health. 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 pre-approve 
implant /abutment supported removable denture for edentulous arch  maxillary (D6110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine home health skilled nursing visits, two home health 
physical therapy visits, and two home health occupational therapy visits. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee underwent a left total hip 
arthroplasty in June of 2022. She is already functioning at a level appropriate for outpatient care. The requested 
home health services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine home health skilled nursing visits, two home health physical therapy visits, and two 
home health occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax charged (code S9999) for the cochlear implant 
provided on February 22, 2022. 
 
You asked the Plan to pay for the sales tax. You say that this item is covered and should be paid. The Plan 
denied your request. The Plan says sales tax is not separately payable. The Plan must follow Medicare rules. 
Medicare rules say that no separate payment is made for sales tax. Therefore, we decided that the Plan does not 
have to pay for the sales tax charged (code S9999) for the cochlear implant provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that your lower denture is loose. The Plan 
denied your request. The Plan says your contract excludes prosthetic replacement within five years of insertion. 
 
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, complete and partial dentures are 
limited to once per arch per 60 months. The record shows that you received a maxillary partial denture (D5213) 
on November 15, 2018 and you received a mandibular partial denture (D5214) on September 13, 2018, and 
your maxillary and mandibular denture benefits have been exhausted.  
 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a 
mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that the enrollee has problems chewing 
and needs the upper partial denture. The Plan denied your request. The Plan says this service is not a covered 
benefit under the enrollee's supplemental dental 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 this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5211).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the prolonged service (99356) provided on January 26, 2022. 
 
You asked the Plan to pay for the prolonged service (99356). You say that the coding is correct, and the service 
is not part of any global period. You say that the medical records support the service, and the claim should be 
reviewed. The Plan denied your request. The Plan says that procedure code 99223 has been processed and paid. 
The Plan also says procedure code 99356 must never be reported as a stand-alone 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 99356 
is an add-on code and has been billed with code 99223, which is an appropriate primary procedure code. Based 
on the claim submitted, Medicare billing criteria have been met. Therefore, we decided that the Plan has to pay 
for the prolonged service (99356) provided on January 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography 
(EMG) provided during surgery on October 28, 2021, billed with codes 95910 and 95886. 
 
You asked the Plan to pay for the NCS/EMG studies as billed. You say that this should be paid as billed. The 
Plan denied your request. The Plan says these codes are 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 95910 is Nerve conduction studies; 7-8 studies. The 
definition of 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, 
done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, 
innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 
procedure) 
 
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 NCS/EMG studies as billed. Our reviewer says that the 
documentation does not support the billed codes. Our reviewer found the procedure report describes "pedicle 
screw stimulation". Pedicle screw stimulation would not be reported with nerve conduction studies procedure 
codes which measure amplitude and latency/velocity.  Therefore, this procedure cannot be verified. Per CPT 
code description "done with nerve conduction, amplitude and latency/velocity study. In this case, nerve 
conduction studies cannot be verified, and therefore this procedure would not be covered. 
 
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 NCS/EMG studies as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography (EMG) provided 
during surgery on October 28, 2021, billed with codes 95910 and 95886.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve an osseous surgery. You say that you are in a lot of pain, and you cannot 
eat. The Plan denied your request. The Plan says the requested dental services are not covered 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 an 
osseous surgery (D4260) provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve oxygen (O2) concentrator. 
 
You asked the Plan to pre-approve oxygen (O2) concentrator. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen (O2) concentrator Our reviewer 
says that the documentation supports that the requested oxygen concentrator is medically reasonable and 
necessary. Our physician reviewer found the enrollee has COPD with nocturnal hypoxemia breathing room air, 
demonstrated in 2019. The enrollee is on oxygen during sleep at 2 liters per minute. The records include an in-
person visit with a pulmonologist on March 31, 2022, documenting the continued need for oxygen at night. Therefore, the enrollee meets criteria for the requested oxygen concentrator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen (O2) concentrator have been met. Therefore, we decided that the Plan 
has to pre-approve oxygen (O2) concentrator.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on March 4, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the attached reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
  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 the CT scan (70450) provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair and accessories. 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that this power 
wheelchair is medically necessary for your continued use due to your medical condition. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by 
the beneficiary. 
 
We looked at the file and Medicare rules. In this case, the record indicates that the wheelchair you are currently 
using is within the reasonable useful lifetime. There is no documentation that the problems with your 
wheelchair are caused by irreparable damage. In addition, there is no indication that the current defects of your 
wheelchair are unable to be repaired. Based on this information, we decided that Medicare rules for coverage of 
a replacement power wheelchair and accessories have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a replacement power wheelchair and accessories.