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

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that you will continue to benefit from skilled 
therapy services. The Plan denied your request. The Plan says the denial of authorization for home health care 
is correct. 
 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 you do not meet the Medicare criteria for home health care. Our physician reviewer found the 
documentation does not support that you require additional skilled rehabilitation or nursing services to 
effectively provide treatment, care, and/or services to improve your condition or establish/perform a 
maintenance program. You have been medically stable without any recent exacerbations of medical problem or 
hospitalizations. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment of dental pain (D9110) provided by a 
participating provider on January 17, 2022. 
 
You asked the Plan to pay for palliative treatment of dental pain. You say that you do not agree with this being 
listed as an emergency. You say that they label everything an emergency if you are making an appointment due 
to tooth pain. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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 pay for palliative 
treatment of dental pain (D9110) provided by a participating provider on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 bone marrow aspirate for the enrollee.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on May 27, 2022 with hyperkalemia and COVID-19 and for alcohol withdrawal support. He is now 
medically stable with no issues that require a physicians evaluation three or more times per week. He requires physical therapy but does not require an intensive inpatient rehabilitation program in an IRF. The IRF services 
are therefore 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on October 14, 2021. 
  You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) (K0848). 
 
You asked the Plan to pre-approve a group 2 PWC. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that all criteria listed in the Medicare Rules section must 
be met for coverage. 
 
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 group 2 PWC. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the member is totally dependent for mobility 
and self-care. She is unable to operate the requested power wheelchair and the physical therapy evaluation has 
recommended a safer, manual wheelchair that will assist with her mobility. 
 
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 group 2 PWC have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair (PWC) (K0848).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (0012M) provided October 21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you believe the evidence supporting the use of 
Cxbladder as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says this service does not meet Medicare's criteria of medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. This test has not been evaluated by the MolDx Programs technical 
assessment process and LCD L35396 cites it as noncovered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of 
five genes (0012M) provided October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 11, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to change dentists 
because the last provider was ordering unnecessary procedures. You also say that the new provider had to 
perform his own x-rays and exam before rendering the filling. The Plan denied your request. The Plan says you 
have exhausted your benefit coverage for this service. 
 
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, comprehensive oral exam is limited to 
one (1) per three (3) years. The record shows that you received a comprehensive oral evaluation (D0150) on 
August 4, 2021 and your comprehensive oral exam benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service September 
24, 2020. 
 You asked the Plan to pay for procedure code 99072. You say that this claim was initially submitted to Original 
Medicare in error. The Plan denied your request. The Plan says no separate payment is made for this 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. 
 
We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99072 billed for date of service September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 30,
2021 and billed under code 92136.
You asked the Plan to pay for this service. 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 for
insufficient claim information. The Plan requested a reopen and provided additional information. The Plan
shows documentation that the provider billed two right professional components, one on August 25, 2021, and
a second on August 30, 2021. The medical records for August 30, 2021, show that only an interpretation was
performed and not a second technical test. Since this service was already performed and billed on August 25,
2021, the August 30, 2021, interpretation is a duplicate service.
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 the Plan has demonstrated that this claim
cannot be paid as billed as the service was previously paid. Medicare rules for coverage of this service have not
been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the
enrollee on August 30, 2021 and billed under code 92136.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (excluding final 
restoration) (D3330) and treatment of root canal obstruction; non-surgical access (D3331) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a root canal and treatment of root canal obstruction to be provided OON. 
You say that you need a root canal as soon as possible and are not able to get a quick appointment in-network. 
The Plan denied your request. The Plan says the services can be provided in-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a root canal 
and treatment of root canal obstruction to be provided OON when the services are provided in-network.  
 
 We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We 
found no exception that would require the Plan to pay for these items/services. Based on this information, we 
decided that the Plan's rules for coverage of a root canal and treatment of root canal obstruction to be provided 
OON have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, 
molar tooth (excluding final restoration) (D3330) and treatment of root canal obstruction; non-surgical access 
(D3331) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) by the provider 
on January 12, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you had to go to an oral surgeon 
because you need an old root canal fixed. The Plan denied your request. The Plan says the benefit limit for 
D0150 has already been exhausted. 
 
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 one 
comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on 
December 21, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) by the provider on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
December 10, 2021, billed with code 99202. 
 
You asked the Plan to pay for the EM services. You say that this was denied as duplicate but neither of the 
claims paid. You feel payment should be made for one of the claims. The Plan denied your request. The Plan 
says it was decided to make payment for the manual manipulation of the spine. However, Medicare does not 
cover EM services from chiropractors. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the evaluation and management (EM) services provided on December 10, 
2021, billed with code 99202.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from October 23, 
2021, to October 29, 2021. 
 
You asked the Plan to pay for home infusion therapy. You say that these services were billed appropriately. 
The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (S9500) provided from October 23, 2021, to October 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided July 28, 
2021. 
 
You asked the Plan to pay for the emergency visit. You say that per your coding department, they have coded 
according to documentation. Please reprocess for payment. The Plan denied your request. The Plan says 
documentation does not support CPT code 99285. CPT code 99284 was applied correctly for services per 
documentation provided. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.  
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency visit. Our reviewer says that 
CPT code 99285 is not supported in the medical record. Our reviewer found in this case, documentation does 
not support CPT 99285. The department documentation support Level CPT 99283. History: Expanded problem 
focused; Exam: moderate complexity; MDM: Moderate complexity. 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on August 3, 
2021, to November 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until July 22, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on August 3, 2021, to November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by a periodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that your original request was 
having 2 teeth loose after a scaling and root planing was performed. You also say that since the original 
request, you have had bleeding gums and it is causing you a lot of pain. The Plan denied your request. The Plan 
says dental services are only covered 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 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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network dental services provided to the enrollee on January 10, 2022.

You asked the Plan to pre-approve the services. You say that the allowed amounts for preventive care are significantly lower than the billed amounts. The Plan denied your request. The Plan says the claim processed appropriately.

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 dental services out-of-network with a likely larger cost-share.

The plan has paid the full applicable allowed amounts for the services at issue in this case. Any further charges are your responsibility. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-network dental services provided to the enrollee on January 10, 2022.