Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214). 
 
You asked the Plan to pay for a complete upper denture and lower partial denture. You say that your old 
dentures do not fit well. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers a complete 
upper denture and lower partial denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dentures were 
previously covered on August 28, 2019. Based on this information, we decided that the Plan's frequency limit 
for coverage of a complete upper denture and lower partial denture will be exceeded with the requested 
services.  Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on December 16, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral 
evaluation. You say that these services were necessary to inform a recommended surgery. The Plan denied 
your request. The Plan says the cone beam CT capture and interpretation is not a covered benefit under your 
dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency 
limitation in the benefit 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, cone beam CT capture and 
interpretation (D0364) is not among those covered under this benefit. The contract says that problem focused 
limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a 
problem focused limited oral evaluation (D0140) on November 22, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the cone beam computed tomography (CT) capture and interpretation (D0364) and problem focused limited 
oral evaluation (D0140) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan of extremity veins including responses to compression 
and other maneuvers provided August 30, 2021. 
 
You asked the Plan to pay for a duplex scan of extremity veins including responses to compression and other 
maneuvers. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says that this provider is not a network provider with the Plan. We have also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. for this out of area case, the Plan failed to provide verification that they 
attempted to request medical records for this date of service. We also found that medical records are missing 
from the case file. Therefore, we decided that the Plan has to pay for a duplex scan of extremity veins including 
responses to compression and other maneuvers provided August 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten bone grafts at time of implant placement (D6104 
x10) and a collection and application of autologous blood concentrate product (D7921). 
 
You asked the Plan to pre-approve the bone grafts and collection and application of autologous blood 
concentrate product. You say that you heard Medicare covers implants and you need a bone graft. The Plan 
denied your request. The Plan says these 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. 
 
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 ten 
bone grafts at time of implant placement (D6104 x10) and a collection and application of autologous blood 
concentrate product (D7921).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 10, 2021.
You asked the Plan to pay for the x-ray. You say that the enrollee revoked their hospice election prior to the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bag hooks, shoe holders, and attendant control for a 
power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that if an attendant control (E2331) is provided in addition to a beneficiary-
operated drive control system, it will be denied as non-covered. 
 
The requested bag hooks and shoe holders do not serve a purpose that is primarily medical in nature. The 
requested attendant control cannot be approved with the already approved beneficiary-operated drive control 
system. Therefore, we decided that the Plan does not have to pre-approve bag hooks, shoe holders, and 
attendant control for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
October 1, 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 enrollee did not have prior authorization for out of network care. Maximus
administratively overturned the Plans denial for a lack of contract information in the case file. The Plan
requested a reopen and provided the required contract information.
The Plan is correct in this case. 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 pay for care from out-of-network providers only
in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The referring provider also is not a network
provider with the Plan. The Plan had network providers available who could have provided the services at issue
in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of
network physician services provided to the enrollee on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the inhalation of nitrous oxide/analgesia, 
anxiolysis (D9230), the drugs or medicaments dispensed in the office for home use (D9630), the application of 
desensitizing medicaments (D9910), the bone replacement graft for ridge preservation-per site (D7953), and 
the guided tissue regeneration-nonresorbable barrier, per site (D4267) provided on October 6, 2021 and 
October 8, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual dental policy. 
 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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230), the drugs or medicaments 
dispensed in the office for home use (D9630), the application of desensitizing medicaments (D9910), the bone 
replacement graft for ridge preservation-per site (D7953), and the guided tissue regeneration-nonresorbable 
barrier, per site (D4267) provided on October 6, 2021 and October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care following the knee surgery 
(CPT code 27447). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you will be having knee replacement 
surgery and the surgery has been approved but your inpatient hospital stay has been denied. The Plan denied 
your request. The Plan says the planned procedure listed under CPT code 27447 is not listed on the CMS 
Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure and there 
is no documentation provided to support the expectation that you will require a greater than two (2) midnight 
stay. The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient 
level of care can be performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that the admitting physician 
reasonably expects that your necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care following the knee surgery (CPT code 27447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive electrophysiologic evaluation (93620).
You asked the Plan to pay this claim. The Plan denied payment stating while a portion of this claim was paid
previously, code 93620 does not meet Medicare billing criteria. Maximus partially overturned the Plans denial
as the case file did not contain documentation of payment of codes 93613, 93623 and 93622. The Plan
requested a reopen and provided proof of payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. We show an edit exists between codes 93620 and 93655. This code pair does not
allow for the use of a modifier to bypass the edit and code 93620 is not separately payable. As stated above, the
Plan provided documentation to show codes 93613, 93623 and 93622 were paid. Therefore, we decided that the
Plan does not have to pay for comprehensive electrophysiologic evaluation (93620).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) and partial lower denture 
(D5214) provided on November 11, 2021, and December 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extraction and partial lower denture. You say that you urgently 
needed to have tooth #19 removed because it was inflamed, painful, you could not eat, and this provider was 
able to see you right away. You also say that you continued to see this provider because he had already done so 
much. The Plan denied your request. The Plan says non-emergency services provided by an OON provider are 
not available with 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the simple 
extraction (D7140) and partial lower denture (D5214) provided on November 11, 2021, and December 16, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce to waive this cost share.
You asked the Plan to waive or reduce 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 Plan contract agreement
and the services and codes billed by your provider. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says you must pay a $45 copayment for physician specialist services.
The Medicare billing guidelines specifically state the provision of testing materials and equipment for home
anticoagulation monitoring (code G0249) is not billed as a durable medical equipment code. This is billed as a
physician service and paid by under the Medicare Physician Fee Schedule. That is why the services to provide
you with testing materials and equipment fall within the physician specialist services benefit category. 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 or reduce to waive the cost share charged for testing materials and equipment for home
anticoagulation monitoring (code G0249).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for nail debridement (code 11721) provided 
on February 8, 2022. 
 
You asked the Plan to reduce the copayment for nail debridement. You say that there should only be a $35 
copayment for this service. You also say this was done in the provider's office, not in the operating room. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment for outpatient surgery or other services provided at an outpatient hospital facility.  
The record shows that nail debridement (code 11721) is considered a surgical procedure. The enrollee has been 
asked to pay the allowed amount of $58.87, which is less than the $350 copayment for nail debridement. Nail 
debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for nail debridement (code 11721) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the medical necessity for the denied procedure/services has not 
been established after clinical review and per the peer-reviewed medical 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 the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osseous surgery (D4260) provided by a participating provider.

You asked the Plan to pre-approve an osseous surgery. You say that these services are medically necessary. The Plan denied your request. The Plan says the requested dental service is not a covered dental benefit.

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 an osseous surgery (D4260) provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flex. 
 
You asked the Plan to pre-approve Tresiba Flex. You say that the enrollee would benefit from resuming 
Tresiba. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription 
drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tresiba Flex.  
 
 
 Benefits for Tresiba Flex may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on October 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on October 14, 2021.