Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 occupational therapy home health visits, 7 physical 
therapy home health visits, 9 skilled nursing home health visits, and 17 home health aide visits. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary. The Plan denied your request. The Plan says home health services are not covered beyond what has 
been approved. 
 
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. The rules say that HHA services may be covered if it is medically necessary for the 
enrollee to receive skilled nursing or therapy. 
 
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 services. Our reviewer 
says that the requested home health services are not medically reasonable and necessary. Our physician 
reviewer found based on the documentation provided the enrollee does not have documented skilled nursing 
needs (i.e. IVs, complex wound care, new ostomy).  The enrollee does not have documented skilled therapy 
needs.  The enrollees care needs appear to be custodial and long-term.  As such, the requested, ongoing, home 
health services are not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 occupational therapy home health visits, 7 physical therapy home health visits, 
9 skilled nursing home health visits, and 17 home health aide visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy, flexible, transoral; with 
control of bleeding, any method (CPT code 43255) provided on August 16, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by 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. 
 
CPT code 43255-59 remains not supported. This code is included in CPT code 43239; therefore, it cannot be 
separately reimbursed. The medical records received do not support that the procedure or service was distinct 
or independent from other services performed; this means the use of the 59 modifier is not supported. Of not, 
the submitted medical records do not indicate that esophagogastroduodenoscopy, flexible, transoral; with 
control of bleeding, any method was performed. Therefore, we decided that the Plan does not have to pay for 
the esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method (CPT code 43255) 
provided on August 16, 2021.
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 enrollee was approved for a 
right total hip arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says the services at issue are not medically necessary. 
 
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 payment are met in this 
case. Our physician reviewer found the enrollee is approved for a right total hip arthroplasty. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the $20 copayments charged for outpatient therapy services
provided from August 6, 2021, to August 30, 2021.
You asked the Plan to waive this cost share. You say that you do not believe these copayments are correct and
you are on a fixed income. The Plan denied your request. The Plan says this copayment was charged based on
the service provided and the Plan contract agreement. Maximus administratively overturned the Plans denial
for insufficient claim and contract information in the case file. The Plan requested a reopen and provided the
required information to support their decision.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay a $20 copayment for each outpatient rehabilitation visit.
You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the $20 copayments charged for outpatient therapy services provided from August 6,
2021, to August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81295, 81298, 81317, 81321, 81162, 
81191, and 81401) provided on June 14, 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 as billed. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81295, 81298, 81317, 81321, 81162, 81191, and 
81401) provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 82306, 82607, 82746, 
83036, 83090, 83970, 84270, 84403, 84439, 84443, 84480, 84481, 84550, 85025, 85651, 86141, and 86780) 
provided on August 12, 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 as billed. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (80053, 80061, 82306, 82607, 82746, 83036, 
83090, 83970, 84270, 84403, 84439, 84443, 84480, 84481, 84550, 85025, 85651, 86141, and 86780) provided 
on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on August 31, 2021. 
 
You asked the Plan to pay for code 99153. 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. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for moderate sedation services 
(99153) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310). 
 
You asked the Plan to pre-approve an electronic connection (E2310). You say that the requested electronic 
connection (E2310) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic connection (E2310). 
 
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 an electronic connection (E2310). Our 
reviewer says that the enrollee does not meet criteria for the requested electronic connection (E2310). Our 
physician reviewer found per clinical documentation, enrollee does have weakness in upper limbs (greater than 
anti-gravity strength), however range of motion of upper limbs was documented as "within functional limits" 
by evaluating therapists. With this level of function, the enrollee would be expected to be able to access the 
separate power functions as necessary and would not require them all accessible with the joystick. 
Additionally, there are no documented specifics of why an electronic connection would be 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 an electronic connection (E2310) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient care from April 30, 2022, forward. 
 
You asked the Plan to pre-approve inpatient care from April 30, 2022, forward. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the services at issue are not 
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 inpatient care from April 30, 2022, 
forward. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the documentation indicates that the enrollee was admitted on April 
11, 2022, and shortly thereafter, was found to have a duodenal stent that had migrated distally and required 
removal. Though esophagogastroduodenoscopy was done in a relatively timely fashion, the enrollee waited two 
weeks for enteroscopy, which was unsuccessful. She then waited nearly another two weeks for surgical 
intervention. During this, nearly one month of waiting for her procedures, she did not have any acute care 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care from April 30, 2022, forward have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient care from April 30, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Closed treatment of metacarpophalangeal dislocation 
(29125) provided on September 13, 2021. 
 
You asked the Plan to pay for code 29125. 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 29125 
is a column II code to column I code 26700. 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 Closed treatment of metacarpophalangeal dislocation (29125) 
provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electronic connection (E2311). You say that the requested expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are medically necessary. The Plan denied your request. The Plan says 
the requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not 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 an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311). Our reviewer says that the 
requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. Our physician reviewer found the member has a neurologic disorder with functional deficits.  She 
meets criteria for use of a power mobility device.  The requested accessories are not medically necessary as she 
does have use of her hands and can operate and control the power options using the switches that are included 
in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two surgical accesses to implant bodies (D6011 x2), and two bone grafts at time of 
implant placements (D6104 x2). 
 
You asked the Plan to pre-approve the endosteal implants, surgical accesses to implant bodies, and bone grafts. 
You say that you need approval for your oral surgery. The Plan denied your request. The Plan says these 
services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two surgical accesses to implant bodies 
(D6011 x2), and two bone grafts at time of implant placements (D6104 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental surgery, extractions, implants and anesthesia 
provided October 8, 2021. 
 
You asked the Plan to pay for the dental surgery, extractions, implants and anesthesia. You say that these 
services were medically necessary. The Plan denied your request. The Plan says these services are not covered 
under your medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental surgery, extractions, 
implants and anesthesia provided October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam computed tomography (CT) scans (D0367, 
D0366, D0365), removal of thickening bone around teeth (D7471), and deep sedation services (D9222, D9223 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services were denied correctly. 
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 cone beam CT scans, 
removal of thickening bone around teeth, and deep sedation services are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve cone beam computed tomography 
(CT) scans (D0367, D0366, D0365), removal of thickening bone around teeth (D7471), and deep sedation 
services (D9222, D9223 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) and bitewing x-rays 
(D0274) provided on November 29, 2021. 
 
You asked the Plan to pay for the intraoral x-rays (D0220 and D0230) and bitewing x-rays (D0274). You say 
that you weren't aware there was a limit for x-rays and the office was not aware that x-rays would not be 
approved. You say that you would have told them you didn't want the x-rays so you wouldn't pay out-of-
pocket. The Plan denied your request. The Plan says you exceeded the benefit limitations. 
 
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, only one intraoral x-ray and one 
bitewing x-ray are covered per calendar year. The Plan paid for the intraoral x-rays and bitewing x-rays 
provided on April 19, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have 
to pay for the intraoral x-rays (D0220 and D0230) and bitewing x-rays (D0274) provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 10, 2022. 
 
You asked the Plan to pay for the crown. You say that your existing crown broke, was not repairable, and had 
to be replaced before getting any pre-authorization. You also say that you were not aware of there being a 
difference in a repair or replacement, but it did not matter because you needed it fixed. The Plan denied your 
request. The Plan says only crown repair is a covered benefit. The Plan also says that new crowns are 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 requested items or services are not 
among those covered under this benefit. The only type of crown benefit that is covered under your plan is 
crown repairs. New crowns are not covered. Therefore, we decided that the Plan does not have to pay for the 
crown (D2740) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exams (D0120 x 2), and prophylaxis (D1110 x 2) 
provided from March 9, 2021, to September 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you needed to change 
dental providers. You also say that you feel you should be reimbursed. The Plan denied your request. The Plan 
says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to 
providers that have opted out of Medicare. 
 
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, dental services performed by a provider 
that has opted out of Medicare are not among those covered under this benefit. The record shows that 
the provider in this case was no eligible for Medicare on the dates of service in this case. Therefore, we decided 
that the Plan does not have to pay for the oral exams (D0120 x 2), and prophylaxis (D1110 x 2) provided from 
March 9, 2021, to September 21, 2021.