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

 
We decided that the Plan does not have to pay for the outpatient office visit (92012) provided on October 28, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you extended treatment in good faith based on the 
expectation of proper reimbursement for services rendered to the enrollee. You are asking for a review and 
reprocessing based on the medical necessity of the treatment to the enrollee. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 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 office visit (92012) provided on 
October 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus Gene Panel testing provided to the enrollee on 
February 10, 2021. 
 
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 a panel constitutes a single procedural service, so one CPT 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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Tempus Gene Panel testing provided to the enrollee on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of non-tunneled centrally inserted central venous 
catheter provided to the enrollee on January 27, 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 modifier was inappropriate for the procedure. 
 
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 36556 is "Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported this service 
with modifier 51 - multiple procedures on same date of service. The documentation does not support that 
multiple procedures were performed. Therefore, this modifier cannot be verified. The service was reported 
incorrectly.  
We looked at this coder's review, the file, and Medicare rules. 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 insertion of non-tunneled centrally inserted central venous catheter provided to the enrollee on 
January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on June 
7, 2021. 
 
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 provider is not certified for Medicare. 
 
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 provider was not eligible to bill Medicare. The plan did not pre-approve the services. 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 durable medical equipment provided to the enrollee on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it is absolutely needed to shower every day 
which is necessary to prevent skin problems. In addition, I use chair for my bowel routine program, then every 
other day I need to be able to go from shower and have bowel movement. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 12, 
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 laboratory tests are included in the dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on January 12, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $325 copayment charged for outpatient surgical services
provided on November 16, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged correctly. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria. The
Plan states on November 16, 2021, the medical records show you received a colorectal cancer screening
(G0105) as well as an esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239)
and dilation of esophagus, by unguided sound or bougie, single or multiple passes (43450). The cost share in
question did not apply to the colorectal cancer screening but did apply to the additional outpatient procedures
performed. According to the medical records, the office visit of November 2, 2021, shows both the screening
and the procedure were ordered by your physician for a diagnosis of iron deficiency, dysphagia, and personal
history of colonic polyps.
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 that you must pay a $325 copayment for outpatient surgical procedures. The records show you had
a colorectal screening for which there was no copayment and esophagogastroduodenoscopy with biopsy for
which the $325 copayment was charged. 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 $325 copayment charged for outpatient
diagnostic services provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crowns and abutments (D6057 and D6065) for the enrollee.
You asked the Plan to pay for these services as coded. You say that this service should be covered by the Plan.
The Plan denied your request. The Plan says the Plan denied coverage stating the request for services is not
coded properly. Maximus overturned the Plans denial stating the services were medically necessary. The Plan
requested a reopen and stated that these two codes conflict with one another because an implant supported
crown does not require an abutment. While the Plan does not dispute that the crowns and abutments were
medically necessary, the submitted codes D6057 and D6065 were a billing mismatch as an implant supported
crown only has two parts, the implant body, and the crown.
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. The issue in this case was
not the services themselves but the way the prior authorization was coded. Therefore, we decided that the Plan
does not have to provide coverage for crowns and abutments (D6057 and D6065) that were inappropriately
coded for approval.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a power tilt and/or recline system with
elevating leg rests (E1012) for the enrollee.
You asked the Plan to provide coverage for a power tilt and/or recline system with elevating leg rests. You say
that this wheelchair accessory system is medically necessary. The Plan denied your request. The Plan says
Medicare coverage criteria are not met. Maximus upheld the Plans denial but named the power elevation
system (E2300) as the item under review. Maximus received information after the decision to show the power
tilt and recline system with elevating leg rests had not been addressed in the decision review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the E1012 accessory system. Based on the medical records provided in the case file and the medical records
provided with the additional information, we have determined the enrollee does not meet these criteria. For
example, the medical records regarding edema are conflicting, stating edema is present by the provider yet the
physician notes state edema is not present. We do not find the medical records provided by the provider and the
physician are consistent and, in some instances, contradict each other. Medicare coverage criteria are not met.
Therefore, we decided that the Plan does not have to provide coverage a power tilt and/or recline system with
elevating leg rests (E1012) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site 
(D7953) provided on December 21, 2021. 
 
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 in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation-per site (D7953) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87799, 87640, 87653, 87482, 80053, 
84443, 83540, 83550, 84550, 83735, 82728, 82746, 85651, and 83036) provided on January 22, 2022. 
 
You asked the Plan to pay for codes 87799, 87640, 87653, 87482, 80053, 84443, 83540, 83550, 84550, 83735, 
82728, 82746, 85651, and 83036. You say that you would like the Plan to reconsider their denial of payment. 
The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (87799, 87640, 87653, 87482, 80053, 84443, 83540, 83550, 84550, 83735, 82728, 82746, 85651, and 
83036) provided on January 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 62360, 62362-59, 62370-59 
provided on October 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like these codes reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support the 
services as they were 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 codes 62360, 62362-59 and 62370-59 are as follows:  
62360 -  Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir  
 
62362 -  Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, 
including preparation of pump, with or without programming  
 
62370 -  Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion 
(includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 
(requiring skill of a physician or other qualified health care professional) 
 
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 the medical services. Our reviewer says that medical records 
do not support the billing of procedure codes 62360, 62362-59 and 62370-59 Our reviewer found the procedure 
performed in the medical records best corresponds with procedure code 62350, implantation, revision or 
repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an 
external pump or implantable reservoir/infusion pump; without laminectomy,  not those codes that were billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded as 62360, 62362-59, 62370-59 provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on February 7, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that this was the first time you had a 
oral evaluation. The Plan denied your request. The Plan says the benefit limit for D0150 has already been met 
and 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. The Plan covers a 
comprehensive oral evaluation once every three years.  
 
We looked at the file, and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on August 2, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive 
oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by an out-of-network provider on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D6752) for tooth 28 and 31, and a pontic (D6242) for tooth 29 
and 30, provided on December 30, 2021. 
 
You asked the Plan to pay for the crowns (D6752) and pontics (D6242). You say that it does not make any 
sense to do two crowns and a partial. You say that you already had a previous bridge in this space. The Plan 
denied your request. The Plan says that this service is 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 covers crowns 
(D6752) and pontics (D6242) when the services are medically necessary and reasonable. 
 
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 a crown (D6752) for tooth 28 and 31, and a 
pontic (D6242) for tooth 29 and 30. Our reviewer says that the documentation provided meets the criteria of 
medically reasonable and necessary for a replacement fixed bridge replacing teeth numbers 29 and 30. Our 
physician reviewer found that the bridge that has been in place for 13 years is defective and must be replaced. It 
is medically reasonable and necessary to replace the bridge with another fixed bridge since teeth numbers 28 
and 31 will require crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown (D6752) for tooth 28 and 31, and a pontic (D6242) for tooth 29 and 30 
have been met. Therefore, we decided that the Plan has to pay for a crown (D6752) for tooth 28 and 31, and a 
pontic (D6242) for tooth 29 and 30, provided on December 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient level of care 
following surgery is medically necessary. The Plan denied your request. The Plan says there is no medical need 
for the inpatient admission for surgery services. 
 
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 pre-approve 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 patient is a 77-year-old female who has primary osteoarthritis of the left 
hip. There are plans for an elective left total hip arthroplasty with prosthetic replacement procedure. This is a 
request for inpatient services related to this procedure. However, the provided records did not reveal any 
medical history of high-risk conditions or recent documentation of clinical instability that would expect the 
patient to require hospital services that would likely cross 2 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 pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210) and dental case management (D9992), 
provided by an out-of-network provider on February 17, 2022. 
 
You asked the Plan to pay for extractions and dental case management. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
extractions (D7210) and dental case management (D9992), provided by an out-of-network provider on 
February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual swingaway, retractable or removable 
mounting hardware for joystick, other control interface, or positioning accessory (E1028). 
 
You asked the Plan to pre-approve the wheelchair accessory. You say that the enrollee is in need of significant 
adjustment to her existing power chair to allow her increased functional independence for activities of daily 
living, reduced risk for hospitalization and increased quality of life. The Plan denied your request. The Plan 
says the records do not support that the enrollee meets the medical necessity criteria for the swing away 
mounting option. 
 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 wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not support that the swing-away mounting option is required 
to accomplish transfers to a chair or bed or to allow the enrollee to get closer to any surface. The requested 
accessories are 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 wheelchair accessory have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the manual swingaway, retractable or removable mounting hardware for 
joystick, other control interface, or positioning accessory (E1028).