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

 
We decided that the Plan does not have to pay for the intestinal plication (44680) provided on September 21, 
2021. 
 
You asked the Plan to pay for the intestinal plication (44680). You say that CPT code 44680 replaced 43999 
and a corrected claim was submitted. You say that notes are attached and the claim should be reprocessed. The 
Plan denied your request. The Plan says procedure code 44050 has been overturned and procedure code 44680 
is not supported by the medical records submitted. 
 
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 44680 is intestinal plication (separate procedure). 
 
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 intestinal plication (44680). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
this procedure was not found in the documentation. Therefore, an intestinal plication procedure cannot be 
verified as performed.  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 intestinal plication (44680) have not been met. Therefore, we decided that 
the Plan does not have to pay for the intestinal plication (44680) provided on September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), lumbar spine; without 
contrast material (72131). 
 
You asked the Plan to pre-approve CT scan. You say that the requested CT scan is medically necessary. The 
Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found there is no specific clinical 
rationale for the requested CT of the lumbar spine. Therefore, the reviewer found that the requested CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT), lumbar spine; without contrast material (72131).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete lower denture set. 
 
You asked the Plan to pre-approve complete lower denture set. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says this service is limited to one per every 60 
months and our records show that this service was last received on 10/02/2019. 
 
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 
complete lower denture set.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty, and extraction (D7140, D7311) provided 
on January 18, 2022. 
 
You asked the Plan to pay for the alveoloplasty and extraction. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
alveoloplasty, and extraction (D7140, D7311) provided on January 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837), provided on July 19, 2021, 
through December 20, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy (90837), provided on July 19, 2021, through December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that IRF care is not medically necessary and the enrollee's needs can be met at a 
lower level of care such as in a skilled nursing facility, at home with home health services or with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that documentation shows that the enrollee has multiple medical conditions and would benefit from 
continued inpatient treatment that focuses on rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 a complete maxillary denture (D5110), and a 
mandibular partial denture (D5214), provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary denture and a mandibular partial denture. You say that 
you lost your denture and then you were in the hospital for a long time. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says the benefit limit for the requested services 
have 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 complete 
maxillary denture and a mandibular partial denture once every five years.  
 
We looked at the file and Medicare rules. The requested services were provided in 2021. Based on this 
information, we decided that the Plan's rules for coverage of a complete maxillary denture and a mandibular 
partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110), and a mandibular partial denture (D5214), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310) provided by a 
participating provider on October 21, 2021. 
 
You asked the Plan to pay for a diagnostic service consultation. You say that you disagree with these charges. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 a 
diagnostic service consultation (D9310) provided by a participating provider on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown and analgesia, anxiolysis,
inhalation of nitrous oxide provided on June 29, 2020.
You asked the Plan to pay for a porcelain/ceramic crown and analgesia, anxiolysis, inhalation of nitrous oxide.
You say that you were not notified that your previously sent fax was unreadable. The Plan denied your request.
The Plan says the claims were not submitted in a timely manner, and the claims need to be submitted within
twelve months of the date of service as indicated in the member's Evidence of Coverage (EOC) on pages 93-97
and page 143.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for a porcelain/ceramic crown and analgesia, anxiolysis, inhalation of nitrous
oxide was not filed until March 4, 2022. This means that more than one calendar year from the date of service
had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a
porcelain/ceramic crown and analgesia, anxiolysis, inhalation of nitrous oxide provided on June 29, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee for July 24, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this service was previously billed and paid by the same group. Maximus overturned the
Plans denial for insufficient claim information in the file to confirm payment. The Plan requested a reopen and
provided additional claim information.
The Plan is correct in the case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for physician services billed to the enrollee for July 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablet, 100mg. 
 
You asked the Plan to pre-approve Ubrelvy. You say that the enrollee is currently using samples of this drug. 
You also say that they are stable. The Plan denied your request. The Plan says the requested drug is considered 
self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Ubrelvy tablet, 100mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, with or without 
wheels (CPT code E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that you are not to walk on the right let for six 
(6) to eight (8) weeks. The Plan denied your request. The Plan says this item not primarily serve a medical 
purpose, and which are not reasonable and necessary to treat an illness or injury are not covered under any 
condition. 
 
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 crutch substitute. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the crutch substitute at issue in this case meets 
Medicare criteria for medically reasonable and necessary as defined in Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k). The crutch substitute has not been found to be safe and effective in the 
peer-reviewed medical literature for the Medicare population. 
 
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 crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, with or 
without wheels (CPT code E0118).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this member does not have complex nursing or medical needs requiring 
a resource intensive inpatient hospital setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for urinary tract 
infection and dehydration and was discharged home. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement K3 foot and microprocessor knee. 
 
You asked the Plan to pre-approve the prosthetic equipment. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested replacement advanced feet exceed 
enrollee's medical needs. 
 
The Plan follows Medicare rules. Medicare rules say that the replacement of foot and knee is subject to the 
criteria listed in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the equipment in question. Our 
reviewer says that the requested prosthetic equipment is not medically reasonable and necessary. Our physician reviewer found you are a 41-year-old male with K3 level prosthetics since 2019. In this case, the 
documentation does not show that the current feet are unable to meet your need. The criteria for replacement 
while still under warranty have not been met in this case. 
 
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 prosthetic equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a replacement K3 foot and microprocessor knee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have no way to get 
to your appointments. The Plan denied your request. The Plan says that you have exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 99233. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says this procedure code is not supported in the 
medical records. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: detailed interval 
history; detailed examination; and medical decision making of high complexity. 
 
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 procedure code 99233. Our reviewer says that procedure 
code 99233 is not supported in the medical record. Our reviewer found per the documentation, the patient was 
admitted on November 2, 2021, and discharged on November 11, 2021.  The dates of service are documented for the first and last dates of inpatient hospital stay.  However, subsequent 
care documentation does not have dates of service documented, and therefore the level of service for each date 
of service cannot be confirmed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 billed for date of service November 4, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the 6 over-the-counter (OTC) coronavirus test kits purchased from 
January 20, 2022, to February 12, 2022. 
 
You asked the Plan to pay for the OTC coronavirus test kits. You say that you were advised you could be 
reimbursed for the OTC tests. The Plan denied your request. The Plan says that reimbursement cannot be made 
for OTC test purchased before April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that that plans and insurers are required to cover at-
home over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC coronavirus test kits have been met. Therefore, we decided that the Plan has to pay for the 
6 over-the-counter (OTC) coronavirus test kits purchased from January 20, 2022, to February 12, 2022.  
 
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.