Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on June 03, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $325 
copayment for Medicare covered surgical services (including diagnostic colonoscopy).  
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that 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 copayment for outpatient surgery on June 03, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) 
provided on May 29, 2022. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that you would like this 
claim to be reconsidered for payment based on medical necessity. The Plan denied your request. The Plan says 
the payment for this service is included in the fee for the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on May 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a permanent spinal cord stimulator (SCS) device.

You asked the Plan to pre-approve implantation of a permanent SCS device. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is not medically necessary.

The Plan follows Medicare rules. The rules say that payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation only when the conditions listed in the Medicare rules section of this letter have been met.

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 implantation of a permanent SCS device. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee needs a trial of SCS prior to permanent implantation. The enrollee would meet criteria for a trial of SCS.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of a permanent SCS device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a permanent spinal cord stimulator (SCS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system, 
any type (E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says a power seat elevation feature is not covered because it is not primarily 
medical in nature. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system, any 
type (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a SPRINT brand peripheral nerve stimulation system for the enrollee.
You asked the Plan to provide coverage for the SPRINT brand system. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial stating the device is not implanted but would be medically beneficial. The Plan requested a reopen and stated the Medicare guidelines require the stimulator to be implanted.
The Plan is correct in the case. The Plan must follow Medicare rules. Medicare provides coverage for this type of device when it is implanted. The SPRINT system does not require permanent implantation. Based on this information, Medicare rules for coverage of the SPRINT brand system have not been met. Therefore, we decided that the Plan does not have to provide coverage for a SPRINT brand system for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for parenteral nutrition (liquid nutrition).
You asked the Plan to provide coverage for liquid nutrition. You say that liquid nutrition is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct
coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare has specific
coverage criteria for parenteral nutrition. The medical records show not show a condition of the small intestine
or disease of the stomach. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not
have to provide coverage for parenteral nutrition (liquid nutrition).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions with four or 
more teeth or tooth spaces, per quadrant (D7310) of the upper left quadrant and alveoloplasty in conjunction 
with extractions with one to three teeth or tooth spaces, per quadrant (D7311) of the upper right quadrant 
provided on April 27, 2022. 
 
You asked the Plan to pay for the alveoloplasties. The Plan denied your request. The Plan says your benefit for 
the requested services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service April 27, 2022. Therefore, we 
decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions with four or 
more teeth or tooth spaces, per quadrant (D7310) of the upper left quadrant and alveoloplasty in conjunction 
with extractions with one to three teeth or tooth spaces, per quadrant (D7311) of the upper right quadrant 
provided on April 27, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee is found to have a subarachnoid
hemorrhage, subdural hemorrhage, intraparenchymal hemorrhage, and non-displaced temporal bone fracture
through the right mastoid. The Plan denied your request. The Plan says the service requested is not supported
based on the records we received. The records do not show that the enrollee is needing skilled therapy or needs
daily nursing care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee received physical, speech and occupational therapy. The enrollee is at
stand-by assist level with functional mobility including gait to one hundred feet x's 2. The enrollee requires
varying assist with activities of daily living skills. The enrollee does not have daily skilled nursing needs that
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled
professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or skilled
therapy on an inpatient basis in a skilled nursing facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization (37223), intravascular ultrasound (37253) and angiography (75710) provided on October 11, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the documentation provided does not support the correct codes were billed. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan demonstrated that code 75710 was denied due to its bundled relationship with other codes billed on the claim. The Plan states code 37233 is not supported in the documentation as code 37229 was approved for the atherectomy of the TP trunk and peroneal artery (one vascular segment). The Plan further states the anterior tibial artery underwent a simple balloon angioplasty, which is reported under code 37232, not code 37233.
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, the Plan has demonstrated that codes 37223, 37253 and 75710 were billed not billed appropriately.
Based on this information, we decided that Medicare rules for coverage these codes have not been met. Therefore, we decided that the Plan does not have to pay the revascularization (37223), intravascular ultrasound (37253) and angiography (75710) provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on December 9, 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 noted that Medicare requires all claims billed for Molecular Diagnostic
Tests to be billed with a unique test identifier. Per L35025, is applicable as per Box (32 for electronic, Box 11
if 32 is empty, if paper Box 32 only) shows the lab was rendered. This LCD clearly shows
that all tests billed within this jurisdiction are required to be billed with a Unique Test Identifier. There is no
Unique Test Identifier issued by MolDX billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim denied due to the omission of a required identifier on the claim. 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 December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 30, 2021.
You asked the Plan to pay for these services. 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 information. The Plan states Medicare requires all claims billed for Molecular Diagnostic Tests to be billed with a unique test identifier. There is no Unique Test Identifier issued by MolDX billed on the claim.
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 the omission of a required unique test identifier. 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 October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal services provided on June 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you went for a simple teeth cleaning and now I get 
a denial. 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. Periodontal services are not 
covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal services are 
not among those covered under this benefit. Additionally, you signed a waiver accepting personal financial 
responsibility for the non-covered services. Therefore, we decided that the Plan does not have to pay for 
periodontal services provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony x3 
(D7240). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs to have impacted wisdom 
teeth removed under general anesthesia. The Plan denied your request. The Plan says items and services in 
connection with the care, treatment, filling, removal, or replacement of teeth or structure directly supporting the 
teeth are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. The Plan did agree to approve the Outpatient facility charges. 
Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony 
x3 (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of implant body (D6010) for 2 teeth, 
prefabricated abutment (D6056) for 2 teeth, supported crown (D6058) for 2 teeth, and a pontic crown (D6245) 
for 1 tooth. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs the dental services to be 
approved. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted and the maximum was pre-approved on 
October 25, 2022. Therefore, we decided that the Plan does not have to pre-approve the placement of implant 
body (D6010) for 2 teeth, prefabricated abutment (D6056) for 2 teeth, supported crown (D6058) for 2 teeth, 
and a pontic crown (D6245) for 1 tooth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), intravenous moderate (conscious) sedation/analgesia services (D9239 and D9243), and therapeutic 
parenteral drug (D9610) provided on June 3, 2022. 
 
You asked the Plan to pay for the endosteal implant, sedation/analgesia services, and therapeutic parenteral 
drug. You say that you believe the sedation should be covered. The Plan denied your request. The Plan says 
these services are not covered benefits under your dental 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. 
 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 
surgical placement of implant body: endosteal implant (D6010), intravenous moderate (conscious) 
sedation/analgesia services (D9239 and D9243), and therapeutic parenteral drug (D9610) provided on June 3, 
2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgery services provided to the enrollee on August 26, 2021.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states that procedure codes 49560-62-59 and 49568-62-59 were paid. The Plan states codes 15734-26, 14301-59, and 14302-59 were denied as not being supported in the records provided.
The Plan states for code 15734-26 is not supported by the medical records submitted. The operative report did not include documentation of a muscle, myocutaneous, or fasciocutaneous flap from the trunk; therefore, this code cannot be verified. Code 15734 may be reported only when myofascial flaps are created by myofascial releases. It is incorrect to report code 15734 for a Rives-Stoppa repair. The Plan also states codes 15734-15738 are not supported by the documentation because a flap contains muscle or fascia does not constitute a muscle, myocutaneous or fasciocutaneous flap. Codes 15734-15738 are reserved for axial pattern flaps. Reporting of a muscle, myocutaneous, or fasciocutaneous flap is always identified by the donor site, never by the recipient site. In 15734-15378, the physician repairs a defect area using a muscle, muscle and skin, or a fasciocutaneous.
Reporting of CPT code 15734-15378 requires that the muscle is mobilized, elevated, isolated on its primary or secondary blood supply and then transferred locally or regionally. The operative report does not support this.
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, the records provided do not support the services denied. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided April 28, 
2022, to May 1, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford to pay 
this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 for inpatient hospital 
care you must pay a $350 copayment per day for days 1-5 and $0 after day 5.  
 
You have been asked to pay $350 per day for inpatient hospital care. The total you owe is $1,050 ($350/day x 3 
days = $1,050). This item/service falls within the inpatient hospital care benefit category. This means that 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 copayment for inpatient hospital care provided April 28, 2022, to May 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite on tooth #20 (D2331), crowns on 
tooth #7, 8, and 9 (D2790), and core build up on tooth #7, 8, and 9 (D2950) provided on May 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary and 
cheaper in Mexico. The Plan denied your request. The Plan says the requested items and services are not 
covered when received outside the U.S. 
 
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 when received outside the U.S. Therefore, we decided that the Plan 
does not have to pay for a resin-based composite on tooth #20 (D2331), crowns on tooth #7, 8, and 9 (D2790), 
and core build up on tooth #7, 8, and 9 (D2950) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 5, 2022. 
 
You asked the Plan to pay for 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 your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 01, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 5, 2022.