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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate (20939). You say that the requested bone marrow 
aspirate (20939) is medically necessary. The Plan denied your request. The Plan says the requested bone 
marrow aspirate (20939) is not medically necessary. 
 
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 bone marrow aspirate (20939). Our 
reviewer says that the requested bone marrow aspirate (20939) is not medically necessary. Our physician 
reviewer found bone marrow aspirate remains experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate (20939) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942-26-59 billed for date of service July 
11, 2022. 
 
You asked the Plan to pay for procedure code 76942-26-59. The Plan denied your request. The Plan says the 
number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
In this case, the MUE for CPT code 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942-26-59 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 76942-26-59 billed for date of service July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104) for 
teeth numbers 29 and 6, gum medication (D4381) for tooth 6, and other drugs and/or medicines (D9630). 
 
You asked the Plan to pre-approve a bone graft at time of implant placement (D6104) for teeth numbers 29 and 
6, gum medication (D4381) for tooth 6, and other drugs and/or medicines (D9630). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says these services are not covered 
under your 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, 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 a 
bone graft at time of implant placement (D6104) for teeth numbers 29 and 6, gum medication (D4381) for 
tooth 6, and other drugs and/or medicines (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower partial metal base (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you went to a dentist, and they put a bridge 
in, and it popped out. You also say that you waited six months and went to a new dentist. 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 Plan's 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 October 7, 2021. 
Therefore, we decided that the Plan does not have to pre-approve lower partial metal base (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a retreatment of previous root canal therapy (D3347) and an amalgam (D2140).
You asked the Plan to pay for the dental services. You say that your plan pays for services rendered by in-network and out-of-network providers. 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 retreatment of previous root canal therapy (D3347) and an amalgam (D2140).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided from January 20, 2021, to March 15, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you do not know why these claims are not being paid. The Plan denied your request. The Plan says that prior authorization was not obtained for the services received.
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/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 items/services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from January 20, 2021, to March 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 20, 2021.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this claim cannot be paid as billed. Maximus overturned the Plan denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria. The Plan demonstrated that this service was inappropriately billed. The Plan states the lab services were billed with modifier QW which is used to show the tests performed are "simple laboratory examinations and procedures that have an insignificant risk of an erroneous result". They are considered "CLIA waived" and therefore require a "CLIA Certificate of Waiver". This service should have been billed with modifier Q0 to show as a investigational clinical service provided in a clinical research study that is in an approved clinical research study or Q1 to show as a routine clinical service provided in a clinical research study that is in an approved clinical research study.
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 an error with the reported modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex-walk system, a Knee-shin flexion swing/stance
phase control, a Knee-shin stance flexion feature, a Multiaxial ankle, an L5850 Above-knee/hip disarticulation,
an L5925 Above-knee/hip disarticulation, and a Flexible protective outer surface cover for the enrollee.
You asked the Plan to provide coverage for prosthetic equipment. You say that the requested prosthetic
equipment 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 that Maximus did not
apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Flex-walk
system, a Knee-shin flexion swing/stance phase control, a Knee-shin stance flexion feature, a Multiaxial ankle,
an L5850 Above-knee/hip disarticulation, an L5925 Above-knee/hip disarticulation, and a Flexible protective
outer surface cover. The Maximus Physician Reviewer determined that the enrollee met the Medicare criteria
for the requested lower limb prosthetic components. The reviewer found that the clinical documentation
showed that the enrollee is at a K3 functional level and would be expected to traverse difficult terrains with
variable cadences. The Plan requested a reopen and stated while the enrollee's prosthetist states that K3
components are indicated for member, member's physician and PT do not support need for K3 components.
"No documentation in the medical record supports that the member is a K3 ambulator."
The Medical records show the enrollee is a now 68-year-old woman who has undergone a right above-knee
amputation. The enrollee required repeat irrigation and debridement. The incision was well healed on May 13,
2022. The Plan is correct in this case. While the prosthetist states that it is anticipated that the enrollee will be a
K3 ambulator, the available clinical documentation in the case file does not support that the enrollee was a
functional K3 ambulator with the ability to traverse most environmental barriers, and with demands for
prosthetic utilization beyond simple locomotion.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of advance foot system have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Flex-walk system, a Knee-shin flexion swing/stance phase control, a Knee-shin
stance flexion feature, a Multiaxial ankle, an L5850 Above-knee/hip disarticulation, an L5925 Above-knee/hip
disarticulation, and a Flexible protective outer surface cover for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced level (K3) prosthetic foot.
You asked the Plan to pre-approve an advanced level (K3) prosthetic foot. You say that this is medically
necessary. The Plan denied your request. The Plan says that the records do not support that you are a K3
ambulator.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an advanced level
(K3) prosthetic foot. Our Medical Director states that there is no clinical documentation in addition to the
Prosthetics Patient Note that supports that the enrollee is a K3 ambulator and requires a K3 foot prosthesis. Our
physician reviewer found that your condition does not meet criteria for coverage of an advanced level (K3)
prosthetic foot.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an advanced level (K3) prosthetic foot have not been met. Therefore, we
decided that the Plan does not have to pre-approve an advanced level (K3) prosthetic foot.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81161, 81411, and 81238) provided
to the enrollee on October 19, 2021, under claim number.
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 these services were previously paid. Maximus overturned the Plans denial for
insufficient claim information. The Plan requested a reopen and provided additional information. The Plan
demonstrated that this claim denied because it was paid on April 18, 2022. Codes 81161, 81411 and
81238 were denied because payment for these codes is included in the payment for code 81439. Documentation
was provided to show $584.90 was paid under code 81439. Codes 81161, 81411 and 81238 could not be paid
separately as providers are required to bill a single code when one procedure is performed.
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 codes in question could not be paid as billed due to their bundled relationship to code 81439.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services (81161, 81411, and 81238) provided to the enrollee on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on May 11, 2020.
You asked the Plan to pay for the eyeglasses. You say that the glasses were necessary. The Plan denied your request. The Plan says that there was no Plan benefit for eyeglasses.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drugs provided on July 8, 2021.
You asked the Plan to waive the coinsurance for the Medicare Part B drugs. You say that you were treated in the emergency department and feel you should only be charged an emergency room copayment. 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 20% coinsurance for Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the Medicare Part B drugs. This item/service falls within the Medicare-covered Part B drug 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 coinsurance for the Medicare Part B drugs provided on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on October 11, 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 claim was billed with an inappropriate modifier. Maximus overturned the Plans denial stating the services provided were medically necessary. The Plan requested a reopen and stated that the issue was not medical necessity but the fact that the claim submitted has billing errors. The Plan states that this claim denied because the service was billed with an inappropriate modifier. Code J0178 was billed without the required anatomic specific modifier (ie; LT (Left side), RT (Right side), and 50 (Bilateral procedure)). These modifiers designate the area or part of the body on which the procedure is performed. The Plan submitted the claim image that shows the required modifier was not reported 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. Providers must report services with the appropriate codes and when required the correct modifier. In this case, this claim cannot be paid as billed due to the omission of the required anatomical 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 October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided to the enrollee on August 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the dental provider does not contract with Medicare or any type of insurance plans. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering dental provider is not eligible to bill Medicare. The plan did not pre-approve these services. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for dental services provided to the enrollee on August 
10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional kyphoplasty services. You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain. The Plan 
denied your request. The Plan says there was no other vertebral fracture identified. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty services are only covered under certain 
medical indications. 
 
The file shows that the Plan has agreed to pre-approve an L2 kyphoplasty. 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 requested services. Our physician reviewer found that there is no other 
fracture on imaging studies. Based on the records, only the approved L2 kyphoplasty should be performed. 
Therefore, the requested additional level is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional kyphoplasty services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (75726, 75774) provided on June 7, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 75726 & 75774 is not supported in the medical record. Specifically, the codes billed are 
inclusive to the primary procedure, code 37244. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (75726, 75774) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required tooth #10 
(D2950). 
 
You asked the Plan to pay for the dental services. You say that the dentist office told you the service would be 
paid for. The Plan denied your request. The Plan says your benefit for the core buildup, including any pins 
when required (D2950) $2,000 dollar limit was met. 
 
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 March 31, 2022. Therefore, we decided that the Plan does not have to pay for core buildup, including any pins when required 
tooth #10 (D2950). The Plan agreed to pay for the inhalation of nitrous oxide/analgesia anxiolysis (D9230) 
provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
April 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you rely on the facility staff to obtain the 
necessary authorizations. You also say that the medically necessary services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on April 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on July 19, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid 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 code 71045 is not supported in the medical record. Specifically, the claim was billed with an 
outpatient place of service (22), however, the record show the enrollee was an inpatient at the time this service 
was provided. Based on this information, we decided that Medicare rules for coverage of the x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on July 19, 
2022.