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

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), intraoral - periapical 
each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-
orally (D0350), and comprehensive oral evaluation - new or established patient (D0150) provided December 
13, 2021. 
 
You asked the Plan to pay for the oral hygiene instructions, additional periapical x-ray, 2D oral photo and 
comprehensive oral exam. You say that you went in for a cleaning and were unaware you would be provided 
uncovered services. The Plan denied your request. The Plan says the oral hygiene instructions and 2D photos 
are not covered under your benefits. You have exceeded the frequency limit for the periapical x-ray and 
comprehensive exam. 
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. The Plan covers a periapical x-
ray once per year and a comprehensive oral exam once every three years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an additional 
periapical x-ray and a periodontal oral exam were previously covered December 13, 2021. Based on this 
information, we decided that the Plan's frequency limits for coverage of the additional periapical x-ray and 
comprehensive oral exam have been exceeded. Though the Plan offers dental benefits in excess of Medicare 
coverage, the oral hygiene instructions and 2D photos are not among those covered services. Therefore, we 
decided that the Plan does not have to pay for the oral hygiene instructions (D1330), intraoral - periapical each 
additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350), and comprehensive oral evaluation - new or established patient (D0150) provided December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint radiofrequency ablation (RFA) provided to 
the enrollee on November 23, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is experimental and unproven. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found RFA of the lateral sacral branches is considered experimental and investigational because of the wide 
variation in efficacy in the peer reviewed literature. Therefore, the procedure was not medically reasonable or 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for sacroiliac joint radiofrequency ablation (RFA) provided to the enrollee on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an Intraoral Periapical X-ray provided April 15, 2021.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says this benefit was exhausted on February 1, 2021. Maximus overturned the
Plans denial for a lack of claim information in the file. The Plan requested a reopen and provided the claim
showing this benefit was already paid once in 2021 and the benefit was exhausted as of February 1, 2021.
The Plan is correct in this case. Medicare does not cover dental services. 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, this benefit was exhausted prior to the April date of
service. Therefore, we decided that the Plan does not have to pay for an Intraoral Periapical X-ray provided
April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labial veneer (D2962) provided by a participating provider 
on November 23, 2021. 
 
You asked the Plan to pay for labial veneer. You say that you were unaware of what the dentist was doing. You 
say that you thought all of these services were covered. The Plan denied your request. The Plan says D2962 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 Plan's 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 labial 
veneer (D2962) provided by a participating provider on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided by a 
participating provider on August 11, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that you were told that these 
services would be covered. The Plan denied your request. The Plan says D7250 is not a covered dental benefit. 
 
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 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 
removal of residual tooth roots (D7250) provided by a contracted provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of the OptiMesh interbody fusion system during 
an approved spinal surgery. 
 
You asked the Plan to pre-approve the OptiMesh interbody fusion system. You say that it is felt that the 
OptiLif interbody fusion system is proven and should be considered medically necessary. The Plan denied your 
request. The Plan says this system is currently being studied for safety and efficacy. It is not currently 
considered medically necessary. 
 
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 OptiMesh interbody fusion system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is scheduled to undergo an L4-L5 decompression and fusion procedure for severe and persistent pain. However, the Optimesh interbody fusion system remains experimental at this time. More research is needed. 
 
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 OptiMesh interbody fusion system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the use of the OptiMesh interbody fusion system during an 
approved spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on April 26, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional billing information. The Plan states that this claim denied
because the provider billed this service inappropriately. The procedure code billed is not the correct code for
the services billed or the date of service billed. The provider should have billed code G2212 in place of 99417
for payment consideration, per the Final Policy, Payment, and Quality Provisions Changes to the Medicare
Physician Fee Schedule for Calendar Year 2021.
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, this claim cannot be paid as billed due to
the omission of the appropriate code. Therefore, we decided that the Plan does not have to pay for medical
services provided to the enrollee on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for services provided from April 29, 2021, to May 28, 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 these services were previously paid. Maximus overturned the Plans denial for
insufficient claim in formation in the case file. The Plan requested a reopen and provided additional
information.
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, this claim
denied because the Plan previously paid for this service under another claim to the same provider on April 5,
2021. The Plan provided documentation to show this payment. Therefore, we decided that the Plan does not
have to pay for medical services provided to the enrollee on April 29, 2021, to May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) represented by code 
K0800. 
 
You asked the Plan to pre-approve a POV. You say that you have fallen 7 times with a walker and need the 
scooter as soon as possible. You say that you are afraid you will do more damage to your body if you continue 
to fall. You say that you have a busted knee. The Plan denied your request. The Plan says the clinical 
information received indicates the enrollee does not utilize a can or walker within the home and would like a 
scooter for use on a cruise ship. The Plan says that there is no clinical information received which indicates that 
the enrollee needs assistance with any activities of daily living. The Plan says that there is no indication that the 
enrollee cannot self-propel a manual wheelchair. The Plan says that there is no evidence to show that the 
enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of 
the POV that you're requesting. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 POV. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the documentation does not support that 
the enrollee has a mobility deficit that impairs mobility related activities of daily living (MRADLs) in the home 
and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair. While the enrollee may 
have the cognition to safely operate the power scooter the documentation does not reveal a home assessment to 
support that the requested device will be able to safely maneuver in the home and access rooms for MRADL 
participation. The documentation does not support that the POV will significantly improve the enrollees ability 
to participate in MRADLs and the enrollee will use it in the home. The documentation does not reveal that the 
requested K0800 motorized scooter is 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 a POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) represented by code K0800.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet denervation services. 
 
You asked the Plan to pre-approve facet denervation services. You say that you are losing your functions and 
ability to get up and move. You say that you are in pain and cannot sleep or walk. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the records do not 
show that the previous radiofrequency ablation services helped the enrollee's symptoms. 
 
The Plan follows Medicare rules. Medicare rules say that facet denervation services are covered when 
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 facet denervation services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found it has been more 
than 3 years since the enrollee received an RFA procedure. Therefore, repeat diagnostic blocks should be 
repeated. The request at this point is considered not medically reasonable or 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 facet denervation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet denervation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. 
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on July 
31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404 and 81479) provided on July 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Rhythm electrocardiogram (93042) provided on September 
9, 2021. 
You asked the Plan to pay for code 93042. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that code 93042 
is a column II code to column I code 93010. 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 Rhythm electrocardiogram (93042) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1851) provided on August 30, 2021. 
 
You asked the Plan to pay for the knee brace. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee brace (L1851) provided 
on August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cystourethroscopy services (52352-51-59, 52330-51-59, 
and 52344-51-59) provided on November 8, 2021. 
 
You asked the Plan to pay for codes 52352-51-59, 52330-51-59, and 52344-51-59. You say that the medical 
records support the use of modifier 59 with codes 52352, 52330, and 52344 provided on November 8, 2021. 
The Plan denied your request. The Plan says the medical records do not support the use of modifier 59 with 
codes 52352, 52330, and 52344 provided on November 8, 2021. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for codes 52352-51-59, 52330-51-59, and 
52344-51-59 Our reviewer says that the medical records do not support the use of modifier 59 with codes 
52352, 52330, and 52344 provided on November 8, 2021. Our physician reviewer found codes 52352, 52330, 
and 52344 are inclusive to CPT 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with 
lithotripsy including insertion of indwelling stent, includes the performance of lithotripsy and the insertion of 
the indwelling stent on the same side). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 52352-51-59, 52330-51-59, and 52344-51-59 have not been met. 
Therefore, we decided that the Plan does not have to pay for the Cystourethroscopy services (52352-51-59, 
52330-51-59, and 52344-51-59) provided on November 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care for the enrollee. 
 
You asked the Plan to pre-approve home health care. You say that home health care is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
 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 home health 
care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on the 
medical record documentation provided, the enrollee does not have documented skilled nursing needs or 
documented skilled therapy needs.  Medicare criteria for ongoing services are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced prosthetic foot system. 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the 
requested foot exceeds your needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
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 requested item. Our physician 
reviewer found that a level 3 ambulator has the ability or potential for ambulation with variable cadence.  
Typical of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion.  
The documentation does not support that you are a level 3 ambulator or have a need in your daily routine for an 
advanced foot/ankle. 
 
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 requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an advanced prosthetic foot system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Januvia. 
 
You asked the Plan to pre-approve Januvia. 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 Januvia.  
 
Benefits for Januvia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.