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

 
We decided that the Plan does not have to pre-approve a full body sling for a heavy-duty power lift. 
 
You asked the Plan to pre-approve full body sling. You say that this is crucial but will do no good if it cannot 
support your weight. The Plan denied your request. The Plan says a full body sling is not separately covered 
because it is already included in the approved patient lift. 
 
The Plan must follow Medicare rules. Medicare rules say that a full body sling is not separately covered when 
provided with a heavy-duty lift because it is included in the allowance for the lift.  
 
We looked at the file and Medicare rules. The Plan has already approved the requested heavy-duty lift, which 
includes the allowance for the full body sling. Based on this information, we decided that Medicare rules for 
coverage of full body sling have not been met. Therefore, we decided that the Plan does not have to pre-
approve a full body sling for a heavy-duty power lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prophylaxis (D1110) and periodic oral evaluation 
(D0120) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are limited with how far you can 
travel. You say that you would like the Plan to pre=approve these services. The Plan denied your request. The 
Plan says dental services from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve prophylaxis 
(D1110) and periodic oral evaluation (D0120) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
tooth #7 (D3950), and surgical procedure for isolation of tooth with rubber dam tooth #7 (D3910). 
 
You asked the Plan to pre-approve the canal preparation and fitting of preformed dowel or post tooth #7 
(D3950), and surgical procedure for isolation of tooth with rubber dam tooth #7 (D3910). The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve canal 
preparation and fitting of preformed dowel or post tooth #7 (D3950), and surgical procedure for isolation of 
tooth with rubber dam tooth #7 (D3910). The Plan agreed to pre-approve periodontal scaling and root planing - 
four or more teeth per quadrant (D4341), onlay - porcelain/ceramic - three surfaces (D2643), and endodontic 
therapy, anterior tooth (excluding final restoration) (D3310).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the enrollee was seen twice on the same date 
of service. The Plan denied your request. The Plan says procedure 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
the code is not separately payable. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for 
date of service June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme CGP Panel genetic 
testing provided on June 9, 2022, billed with multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Solid Tumor & 
Heme CGP Panel genetic testing provided on June 9, 2022, billed with multiple codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you were active and independent prior to your
hospitalization and wish to return to being independent as quickly as possible. You say you are eager to
participate in therapy and will not receive adequate services in a lower level of care. The Plan denied your
request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of
care such as a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care (ex. skilled nursing facility, home health services, outpatient
therapy).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge () 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements necessary to be approved. 
 
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 
dental bridge ()
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), extractions 
(D7140 x3), and does not have to pay an additional amount for a limited oral evaluation (D0140) provided on 
September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to cover the panoramic 
radiographic image and extractions and pay an additional amount for the examination The Plan denied your 
request. The Plan says the panoramic radiographic image and extractions were received from an out-of-network 
provider and are not covered by your supplemental benefits. You are responsible for any charged amount above 
the Plans cost-sharing amount for the examination when your services are received from an out-of-network 
provider. 
 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the panoramic radiographic image and extractions are 
not covered under this benefit when received from an out-of-network provider. You have been asked to pay the 
difference between the out-of-network providers charges and the Plans payment for the limited oral 
evaluation. 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 pay for a panoramic radiographic image (D0330), 
extractions (D7140 x3), and does not have to pay an additional amount for a limited oral evaluation (D0140) 
provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment - includes modification and placement (D6056) and abutment supported 
porcelain/ceramic crown (D6058), for Tooth #8, #9, #10. 
 
You asked the Plan to pre-approve dental services. You say that you really need this procedure, so you can 
have a better quality of life. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Surgical placement of implant 
body: endosteal implant (D6010), prefabricated abutment - includes modification and placement (D6056) and 
abutment supported porcelain/ceramic crown (D6058) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant (D6010), prefabricated abutment - includes modification 
and placement (D6056) and abutment supported porcelain/ceramic crown (D6058), for Tooth #8, #9, #10.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second unit of procedure code 51798 billed for date of 
service August 10, 2021. 
 
You asked the Plan to pay for procedure code 51798. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 51798 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of the second unit of procedure code 51798 have not been met. Therefore, we 
decided that the Plan does not have to pay for the second unit of procedure code 51798 billed for date of 
service August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 24, 2022.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on December 8, 2021, rather than the billed date of service January 24, 2022. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid as billed due to an issue with the date of service billed and the date of specimen collection billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $252.69 cost share charged for chiropractic services provided on January 6, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The breakdown of the services provided is as follows:
1. office visit (code 99203) not covered, $123.00
2. chiropractic manipulative treatment (code 98940), coverage with 50% coinsurance out of network, $15.69
3. physical therapy services (code 97110), not covered in a chiropractic setting, $43
4. physical therapy services (code 97112), not covered in a chiropractic setting, $38
5. physical therapy services (code 97014), not covered in a chiropractic setting, $33 Codes 99203, 97110, 97112 and 97014 are not manual manipulation of the spine and are not covered in a chiropractic setting. Therefore, we decided that the Plan does not have to waive the $252.69 cost share charged for chiropractic services provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an addition to a prosthetic knee-shin system.
You asked the Plan to provide coverage for this request. You say that at the time of the appeal the requested
prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the codes
requested for prior approval were incorrect and exceeded the enrollees needs. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes
the approved knee is the College Park Capital knee. The requested codes include code L5845. The coding
guidelines show while several knees use code L5845, College Park Capital knee is not one of them. Code
L5845 cannot be used for this device and is unbundled. While the manufacturer uses code L5845 for this
knee, neither the manufacturer nor the vendor has the authority to assign this code to the requested
knee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. When submitting a request for prior authorization or coverage for an item or service,
Providers must do so with the appropriate codes.
The prosthetic part requested is already included with the approved knee and cannot be requested separately.
Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for an addition to a prosthetic knee-shin system for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided the Plan does not have to pay for non-physician services provided on December 31, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this claim was not billed appropriately. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
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 and when necessary, the appropriate modifier. In this case the claim was not submitted with the required modifier.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for non-physician services provided to the enrollee on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 99220. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99220 is bundled into payment for code 90935. 
 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 99220 
is a column II code to column I code 90935. 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 99220 billed for date of service August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation (D0150). You say that your dentist referred 
you to see an orthodontist specialty. The Plan denied your request. The Plan says the member's contract only 
provides coverage for dental services when they are performed by a participating general dentist. The Plan also 
says that dental services performed by a periodontist 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 
comprehensive oral evaluation (D0150).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 10, 2022 to April 
28, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the "through" date (April 28, 2022) was billed incorrectly as the 50th day from the "from" date. 
Therefore, we decided that the Plan does not have to pay for home health services provided on March 10, 2022 
to April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy and occupational therapy. 
 
You asked the Plan to pre-approve physical therapy and occupational therapy. You say that the services are 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy and occupational 
therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found you do not require continued skilled input. You 
may continue with a repetitive exercise program as you do not require input from a skilled therapist to continue 
exercise. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy and occupational therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve physical therapy and occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the decision to prescribe IGRT is based on the 
enrollee's medical history and available treatment options that would result in the best clinical outcome. The 
Plan denied your request. The Plan says this is 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer, but is not necessary. Therefore, to 
bill for daily simple simulations and/or IGRT for a technology for which the need has not been established by 
published data or supported by consensus guidelines is unnecessary. This would not be furnished in accordance 
with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).