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

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on December 
29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (83789-59) provided on December 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with codes 95909, 95886 and 95955 for 
October 28, 2021. 
 
You asked the Plan to pay for services billed with codes 95909, 95886 and 95955. You say that these services 
were medically necessary and were billed appropriately. The Plan denied your request. The Plan says these 
services are not supported in the medical record as billed. 
 
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, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 95909 is nerve 
conduction studies; 5-6 studies. The CPT Code Manual definition of code 95955 is electroencephalogram 
(EEG) during nonintracranial surgery (e.g., carotid surgery). We asked our coder 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 services billed with codes 95909, 95886 and 95955. Our 
reviewer says that these services are not supported as billed. Our reviewer found that procedure code 95909-26 
is not supported by the medical records submitted. The technical report did not include documentation of a 
nerve conduction studies for 5-6 studies; therefore, this code cannot be verified. Procedure code 95886-26 x2 is 
not supported by the medical records submitted. The technical report did not include documentation of a 
complete needle electromyography, per each extremity with related paraspinal areas when performed, done 
with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by 
three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); 
therefore, this code cannot be verified. Procedure code 95955-26-59 is not supported by the medical records 
submitted. The technical report did not include documentation of an electroencephalogram (EEG) during 
nonintracranial surgery (carotid surgery); therefore, this code cannot be verified. The review has determined 
that the documentation provided did not support the billing of CPT codes 95909, 95886 (x2) and 95955 for the 
date in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services billed with codes 95909, 95886 and 95955 have not been met. 
Therefore, we decided that the Plan does not have to pay for services billed with codes 95909, 95886 and 
95955 for October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia procedure (99135) provided on 
December 21, 2021.  
You asked the Plan to pay for the special anesthesia procedure. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
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 99135 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99135 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for the special anesthesia procedure (99135) provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) therapy.

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CPAP therapy is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have obstructive sleep apnea (OSA) and use a CPAP with benefit. Your clinician advised you stop using the Respironics device. You have not yet been provided with a replacement device. There are no records supporting that the device should be replaced by the Plan due to manufacturer recall.

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 continuous positive airway pressure (CPAP) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for dental splints and related services for the enrollee.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal, you stated
this treatment was medically necessary. The Plan denied your request. The Plan says this was a dental service
and is not covered under the Plan benefit. Maximus overturned the Plans denial stating these splints were
required to treat TMJ. The Plan requested a reopen and stated that the Plan contract specifically states this
treatment is not covered.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The enrollee has a
diagnosis of TMJ. The Plan contract specifically states dental splints and related services provided for the
treatment of TMJ are not covered. Therefore, we decided that the Plan does not have to provide coverage for
dental splints and related services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood oxygen level measurement (94760) provided on 
August 24, 2021. 
 
You asked the Plan to pay for blood oxygen level measurement (94760). The Plan denied your request. The 
Plan says this service is always bundled into another payable physician 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. 
 
We find that CPT code 94760 has a status indicator of T on the Physician Fee Schedule and was billed with 
another payable service. This means that CPT code 94760 is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of blood oxygen level measurement (94760) have not been met. 
Therefore, we decided that the Plan does not have to pay for blood oxygen level measurement (94760) 
provided on August 24, 2021.
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 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 this is a duplicate claim as the required modifier was not included on the claim.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan demonstrated that this claim denied because the Plan previously paid for this service under another claim.
The appealed claim was billed inappropriately and did not support why this procedure had been rendered twice
on the same day. The provider needed to bill with Modifier 26 to show the service provided was the reading
and interpreting of the results of a diagnostic and/or laboratory service; Or with Modifier 91 to show the
laboratory test(s) were performed more than once on the same day on the same patient.
The Plan states according to the Medicare Claims Processing Manual, Chapter 1 for General Billing
Requirements (Section 120 - Detection of Duplicate Claims) "The claims processing systems contain edits
which identify exact duplicate claims and suspect duplicate claims. All exact duplicate claims or claim lines are
auto-denied or rejected (absent appropriate modifiers). Suspect duplicate claims and claim lines are suspended
and reviewed by the claims administration contractors to decide to pay or deny the claim or claim line."
The Plan further states that Section 120.3 for Suspect Duplicates, states "Suspect duplicates are claims or claim
lines that contain closely-aligned elements sufficient to suggest that duplication may be present and, as such,
require that the suspect claim be reviewed. Suspect duplicate edits can be hard coded in the system or local
edits set up by Medicare contractors." And "The criteria for identifying suspect duplicate claims submitted by
physicians and other suppliers are not published and vary according to the type of billing entity, type of item or
service being billed, and other relevant criteria. The denial of claim as a duplicate of another claim may be
appealed when the denial is based on criteria other than those specified above for exact duplication." Therefore,
the Plan continues to state the denial was appropriate based on Medicare billing guidelines.
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, the second claim cannot be paid as billed due to the omission of the
required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for physician services provided to the enrollee on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230), and extractions (D7140 and D7210) provided on September 28, 2021, and 
October 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have always used this dentist and have 
never been asked for a copay. You also say that the Plan and dentist both advised that these services would be 
covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered 
because your healthcare plan does not have OON 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental 
services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230), and extractions (D7140 
and D7210) provided on September 28, 2021, and October 20, 2021 by an out-of-network (OON) provider.
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 has 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. Bone marrow 
aspirate remains experimental. More research is needed to show safety and efficacy when used as bone graft 
material. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two resin-based composites (D2392 x2) provided 
on February 10, 2022, and February 17, 2022. 
 
You asked the Plan to pay more for the resin-based composites. You say that you feel these services should be 
covered because you received a bill even though you already paid the amount. You also say that the provider 
says you still owe $56. The Plan denied your request. The Plan says your resin-based composite claims were 
processed under an alternate benefit of an amalgam, and you are responsible for the difference between the 
allowed amounts. 
 
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, if a method of treatment is more costly 
than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be 
responsible for the remaining balance. The record shows that these resin-based composites were processed 
under the alternate benefit of amalgams, and you are responsible for the 50% coinsurance plus the difference 
between the allowed amounts. Therefore, we decided that the Plan does not have to pay more for the two resin-
based composites (D2392 x2) provided on February 10, 2022, and February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81292 and 81294 provided on 
May 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 81292 and 81294 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was billed for the services rendered. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81292 and 81294 
provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) on March 14, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service provided by a dentist or physician other than requesting dentist or physician (D9310) on 
March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for introduction of needle or intracatheter (36000) provided on 
December 11, 2021.  You asked the Plan to pay for introduction of needle or intracatheter (36000). The Plan denied your request. 
The Plan says bundled services are not eligible for separate payment. 
 
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 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of introduction of needle or intracatheter (36000) have not been met. Therefore, we decided that the Plan does 
not have to pay for introduction of needle or intracatheter (36000) provided on December 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on September 19, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 the gene panel at issue was billed with multiple codes. If a single procedure is performed, only 
one code with one unit of service may be reported for the procedure. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on September 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the intraoral-periapical each additional radiographic image (D0230) provided on February 8, 2022. 
 
You asked the Plan to pay for these services. 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 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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical first radiographic image (D0220) and the intraoral-periapical each additional radiographic image 
(D0230) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral x-rays 
(D0220) provided on February 1, 2022, endodontic therapy (D3310) provided on February 7, 2022, and a resin-
based composite filling (D2330) and root canal (D3331) provided on February 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have always been paid for services by this 
provider. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) and intraoral x-rays (D0220) provided on February 1, 2022, 
endodontic therapy (D3310) provided on February 7, 2022, and a resin-based composite filling (D2330) and 
root canal (D3331) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided by a participating provider on March 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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 February 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110 and D5120) provided by a participating provider on March 10, 2022.