Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for anesthesia services coded as 00920 provided on April 22, 2021.
You asked the Plan to pay for anesthesia services coded as 00920. 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 provided additional information. The Plan provided documentation to
show the claim was denied because procedure code 00920 (anesthesia services) was bundled with a previously
paid claim. The bundled codes were paid on May 27, 2021, in the amount of $322.37.
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 provided documentation to
show these services were previously paid. Therefore, we decided that the Plan does not have to pay for
anesthesia services coded as 00920 provided on April 22, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no 
documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and 
occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration because this 
testing is required before surgery. The Plan denied your request. The Plan says the enrollee does not have out-
of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the genetic testing to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the decompression of the lumbar spine, utilizing the 
Vertiflex interspinous spacer and utilizing the Aurora Spine ZIP Interspinous Fixation System (22840, 22612, 
and 63030). 
 
You asked the Plan to pre-approve the decompression of the lumbar spine, utilizing the Vertiflex interspinous 
spacer and utilizing the Aurora Spine ZIP Interspinous Fixation System. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the decompression of the lumbar spine, 
utilizing the Vertiflex interspinous spacer and utilizing the Aurora Spine ZIP Interspinous Fixation System. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental and more research is needed to show safety and 
efficacy. 
 
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 decompression of the lumbar spine, utilizing the Vertiflex interspinous 
spacer and utilizing the Aurora Spine ZIP Interspinous Fixation System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the decompression of the lumbar spine, utilizing the 
Vertiflex interspinous spacer and utilizing the Aurora Spine ZIP Interspinous Fixation System (22840, 22612, 
and 63030).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scan services provided to the
enrollee on July 7, 2020, and billed under code 70450.
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 that this code cannot be paid separately. Maximus overturned the Plans denial for
insufficient explanation regarding the coding issue. The Plan requested a reopen and provided additional
information. The Plan demonstrated that mutually exclusive edits consist of combinations of procedures that
differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures
may be anatomically impossible. Procedures that represent overlapping services are considered mutually
exclusive. Procedure codes 70450 and 70496 include imaging of the head or brain. Procedure 70496 however,
is a more comprehensive procedure that includes imaging procedures 70450 as well as additional components.
Therefore, this service cannot be paid separately.
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 code. In this case this claim
cannot be paid as billed as code 70450 was not billed appropriately. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography
(CT) scan services provided to the enrollee on July 7, 2020 and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0602) and 
scaling in presence of generalized moderate to severe gingival inflammation (D4346) provided on November 
11, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be approved. You say that 
these services were to treat your gum disease. The Plan denied your request. The Plan says caries risk 
assessment and documentation is not listed as a covered service. The Plan also says scaling in the presence of 
gingival inflammation is not listed as a covered service either. 
 
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 caries risk assessment and 
documentation, and scaling in the presence of gingival inflammationare not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the caries risk assessment and 
documentation (D0602) and scaling in presence of generalized moderate to severe gingival inflammation 
(D4346) provided on November 11, 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 
December 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that you are on a fixed income. You say that you had 
to go to a new dentist when you moved. You say they were very far away. You say that you went to a closer 
dentist for your 6 month check up. You also say that you were not aware there would be a $100 charge. The 
Plan denied your request. The Plan says a comprehensive oral evaluation is covered once every 3 plan years. 
The Plan also says that the frequency limit has been exceeded. 
 
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 and a comprehensive oral evaluation is covered once every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid 
for a comprehensive oral evaluation that you received on April 28, 2021. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on November 11, 2021. 
 
You asked the Plan to pay for the simple extraction. You say that in your plan materials, under Extractions and 
Oral Surgery, shows that this code is covered. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. The Plan also says that you did not elect to enroll in the available dental 
rider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the simple 
extraction (D7140) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (code D7953) provided on 
December 2, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that your dentist said the bone needs to be 
built up after tooth extractions, so this should be covered. The Plan denied your request. The Plan says this 
service is not covered under your dental 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. Your contract says that the 
dental benefit includes coverage only for those services explicitly listed in your Dental Plan Benefits chart. The 
bone replacement graft (code D7953) is not listed as a covered benefit in this chart. 
 
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 bone 
replacement graft (code D7953) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, prefabricated post and core, pontic and 
retainer crown. 
 
You asked the Plan to pre-approve core buildup, prefabricated post and core, pontic and retainer crown. You 
say that you are constantly taking antibiotics for this infection, you are diabetic and have sensitivity in your 
gums. You say that the services are urgent and need them covered. The Plan denied your request. The Plan says 
the lower partial denture was approved, and the remaining services are denied as they are not covered benefits. 
 
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 core 
buildup, prefabricated post and core, pontic and retainer crown.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (specimen testing) provided to the enrollee on
January 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 payment for this service would be included in the facility
PPS payment. Payment for this service is the responsibility of the facility not the Plan.
The Plan is correct in this case. Medicare does not pay any provider or supplier other than the facility or
hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered
services to the beneficiary either directly or under arrangements made with outside providers.
This specimen was taken from the enrollee during a facility stay. The facility chose to send out the specimen
for review. Payment for this service should be submitted to the facility and not the Plan. The Plan has paid the
facility services and any residual lab services performed for the enrollee in the context of the facility claim.
Payment for this service would have been included under the facility claim. Payment to you for this service is
the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for lab
services (specimen testing) provided to the enrollee on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional resin-based composite of one surface (D2330) 
and resin-based composite of four or more surfaces (D2335) provided on November 29, 2021, and December 
13, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you would like these services to be 
covered. The Plan denied your request. The Plan says this claim processed correctly according to your plan 
benefits. 
 
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, restorative services are limited to up to 
2 visits every year. The record shows that you received three resin-based composites of one surface (D2330 x3) 
on December 13, 2021, two of which were covered by the Plan, and your restorative services benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the additional resin-based composite of 
one surface (D2330) and resin-based composite of four or more surfaces (D2335) provided on November 29, 
2021, and December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services billed with codes D6010, D9223 and D1999 
billed for date of service March 31, 2021, and dental services billed with codes D6069, D6056, and D6240 for 
date of service October 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had these services done because you 
couldn't chew at all. You say that the Plan paying for these services will be a great help to you. The Plan denied 
your request. The Plan says it has paid for dental codes D0230 and D0220, but these other services 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. The Plan's contract says that 
only those dental services explicitly listed in your benefits chart are covered. Dental services with represented 
by codes D6010, D9223, D1999,D6069, D6056, and D6240 are not listed as covered services in the benefits 
chart. 
 
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 dental 
services billed with codes D6010, D9223 and D1999 billed for date of service March 31, 2021, and dental 
services billed with codes D6069, D6056, and D6240 for date of service October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided to the enrollee from March 18,
2021, to April 6, 2021.
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 in the case file. The Plan requested a
reopen and provided additional information. The Plan provided documentation to show this claim denied
because the service was billed with an inappropriate diagnosis code. The Plan stated the Medicare Claims
Processing Manual Chapter 8 explains that ESRD facilities submitting claims for Acute Kidney Injury
services must bill with an appropriate diagnosis code and a condition code of 84. The claim shows the provider
did not bill this service with the condition code of 84, which shows dialysis for Acute Kidney Injury (AKI) on a
monthly basis.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case this claim
could not be paid due to the omission of the appropriate codes. Medicare rules for coverage of this service have
not been met. Therefore, we decided that the Plan does not have to pay for dialysis services provided to the
enrollee from March 18, 2021, to April 6, 2021.
Sincerely,
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scan services provided to the
enrollee from March 29, 2021, to March 31, 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 for
insufficient information in the case file to explain the denial. The Plan requested a reopen and stated that based
on the Medicare billing guidelines, code 77014 is included in the APC payment for code 77301 (IMRT
planning).

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. Medicare does not allow
the billing of code 77014 in addition to the billing of code 77301. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for computed tomography (CT) scan services
provided to the enrollee from March 29, 2021, to March 31, 2021, and billed under code 77014.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface (Bipap) device (E0470). 
 
You asked the Plan to pre-approve a Bipap device. You say that the item is medically necessary/ The Plan 
denied your request. The Plan says the member doesnt have a sleep test showing these results and you have 
not failed a trial of CPAP. 
 
The Plan must follow Medicare rules. Medicare rules say that all the criteria listed in the Medicare Rules 
section of this letter must be met for the item to be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Bipap device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a respiratory assist device, bi-level pressure capability, without backup rate feature, used with 
noninvasive interface (Bipap) device (E0470).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical removal of implant body (D6100) provided on January 24, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and surgical removal of implant 
body. You say that you would like the Plan to pay 50% of the cost of these services. The Plan denied your 
request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that 
you did not contact the Plan prior to the date of service to verify benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and surgical removal of implant body (D6100) provided on 
January 24, 2022.