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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you have a history of falling, with the 
most recent hospital stay being due to falls leading to infection and memory loss. The Plan denied your request. 
The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's 
needs may be met at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with a 
history of heart disease and diabetes who was admitted to the hospital on April 15, 2022, with weakness, acute 
kidney injury, rhabdomyolysis, hyperkalemia, and encephalopathy. As of April 22, 2022, physical therapy was 
recommended three times per week.  
 
No required skilled nursing services are identified in the records provided. Though further skilled therapy is 
appropriate, the documentation does not support that it is medically reasonable and necessary to provide skilled 
therapy services for the enrollee in this case on a "daily basis" on an inpatient basis, in a skilled nursing facility 
setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 26, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that the medical records support the billing of 
these services. The Plan denied your request. The Plan says it has paid for code 99285 billed on this date of 
service, but code 99053 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that services billed under the Medicare Physician Fee 
Schedule that have a status indicator of B, payment is always bundled into payment for other services. No 
separate payment is ever made. Procedure code 99053 has a status indicator of B on the Medicare Physician 
Fee Schedule Database. Therefore, we decided that the Plan does not have to pay for procedure code 99053 
billed for date of service August 26, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve CT scan services. You say that this imaging service is medically necessary. 
The Plan denied your request. The Plan says that the requested CT scan is not medically necessary at this time. 
 
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 services. Our reviewer says 
that the requested CT scan is medically reasonable and necessary. Our physician reviewer found that the patient 
is a 69-year-old female with a history of endometrial carcinoma which was diagnosed and treated with 
hysterectomy in 2015/2016 and is now being monitored. CT imaging was also monitored for 6 years with the 
most recent CT from 2021 showing no evidence of recurrence. She reports intermittent lower abdominal 
pain/discomfort for the past 2 months and examination revealed right lower quadrant discomfort/tenderness but 
no rebound or guarding and no mass was documented as palpated. There is a known umbilical hernia that was 
stable on imaging from 2021 but was not noted on the recent exam. CT abdomen and pelvis was requested. 
Following 5 years of no recurrence of the cancer, guidelines suggest no more imaging surveillance is needed. 
However, due to the patient having new intermittent abdominal pain and unclear findings on examination or 
history, repeat CT is reasonable at this time. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) scan with computed 
tomography (CT) scan from skull to mid thigh (78815) 
 
You asked the Plan to pre-approve PET scan with CT scan. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says that the clinical setting of the case does not support the imaging 
service at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan with CT scan. Our reviewer 
says that the requested services are medically reasonable and necessary. Our physician reviewer found the 
patient has a history of breast cancer from 2001. You have no clinical symptoms but carcinoembryonic antigen 
(CEA) has risen from 4-7. In this case, the NCD specifically allows a PET CT scan for subsequent treatment 
strategy formerly called restaging and monitoring response to treatment. The requested imaging service is 
medically reasonable and 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 PET scan with CT scan have been met. Therefore, we decided that the Plan has 
to pre-approve positron emission tomography (PET) scan with computed tomography (CT) scan from skull to 
mid thigh (78815)  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on November 9, 2021. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that you were informed by the Plan that 
your copayment would only be $180. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for advanced imaging services received at an outpatient hospital.  
 
 You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 reduce 
the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on November 9, 
2021.  
 
Your complaint about the Plan representative giving misinformation about copayment amounts is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on January 3, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you believe this service should be 
covered, and you should still be allowed two additional cleanings because this service was not covered. The 
Plan denied your request. The Plan says this procedure is not a benefit under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 
16, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that your two service appointments for 
preventive dental care were May 13, 2021, and December 16, 2021. You also say that you called another dental 
practice to inquire about a quote for dentures, and were assured there was no cost or charge to you for a quote. 
The Plan denied your request. The Plan says you are allowed two dental preventive exams in a calendar year. 
The Plan also says that you purchased the enhanced dental coverage, which does not include additional 
preventive exams. 
 
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, you are limited to two preventive 
exams. The record shows that you received oral exams on May 13, 2021, and June 9, 2021 and your preventive 
exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 28, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this 
service should be covered. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you contacted the Plan prior to this date of service to locate in-
network providers. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on December 28, 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 x2), and topical application of fluoride varnish (D1206), or pay more for the 
periodic oral evaluation (D0120), and prophylaxis (D1110) provided on November 4, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the intraoral periapical x-rays, and topical application of fluoride varnish, and to 
pay more for the periodic oral evaluation, and prophylaxis. You say that you saw a new dentist. You also say 
that you wished they talked to you about dental. The Plan denied your request. The Plan says intraoral 
periapical x-rays and topical application of fluoride varnish are not covered expenses under your dental plan. 
The Plan also says that these services were performed by a non-participating provider, and you are responsible 
for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. 
 
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, first intraoral periapical x-ray (D0220), 
additional intraoral periapical x-ray (D0230), and topical application of fluoride varnish (D1206) are not among 
those covered under this benefit. The contract also says you are responsible for a 50% coinsurance for the 
periodic oral evaluation (D0120) and prophylaxis (D1110), plus the difference between the billed amount and 
allowed amount because these services were 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 x2), and topical application of fluoride varnish (D1206), or pay more for the periodic oral 
evaluation (D0120), and prophylaxis (D1110) provided on November 4, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 10, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the bitewings that were taken on December 10, 
2021, were critical to confirming that a broken tooth was in immediate need for extraction. The Plan denied 
your request. The Plan says the frequency limit for this service has been exceeded. 
 
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, bitewing x-rays (D0274) are limited to 
one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on March 12, 2021 
and your bitewing x-rays (D0274) benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the bitewing x-rays (D0274) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided December 21, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you feel you had a routine dental 
cleaning which should be covered. The Plan denied your request. The Plan says that the service provided was 
not a routine dental cleaning. The Plan also says that you have exceeded the frequency limit for the 
comprehensive exam. 
 
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 the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on July 9, 2020. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided December 
21, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need wound care to prevent infections which 
you cannot provide for yourself. The Plan denied your request. The Plan says that the Skilled Nursing Facility 
(SNF) services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that you 
meet the Medicare criteria for SNF care. Our physician reviewer found you do have documented skilled 
nursing needs, in the form of twice daily and as needed dressing changes. Our reviewer found that you do not 
have documented skilled therapy needs.  Daily skilled services are required to establish a maintenance program 
or to prevent deterioration of your condition. Our physician reviewer also found that your care needs, as a 
practical matter, would be less well served at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 
 
 
 
 
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that the analysis can help qualify patients for 
target therapies. The Plan denied your request. The Plan says a panel of tests should be billed under a single 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 The file shows that circulating tumor cell (CTC) testing was provided. We looked at the file, and Medicare 
rules. No data has been forthcoming to demonstrate improved patient outcomes, or that the assay changes 
physician management to demonstrate improved patient outcomes. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noncontact real-time fluorescence wound imaging, for 
bacterial presence, location, and load provided on October 1, 2021, billed with code 0598T. 
 
You asked the Plan to pay for the fluorescence wound imaging. You say that this is a payable code under 
Medicare and has an approved fee. The Plan denied your request. The Plan says no records were submitted to 
support the need for this service.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the noncontact real-time fluorescence 
wound imaging, for bacterial presence, location, and load provided on October 1, 2021, billed with code 
0598T have been met. Specifically, no medical records for the billed services were submitted for review, 
despite documented requests from the Plan for the records. Therefore, we decided that the Plan does not have 
to pay for the noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load 
provided on October 1, 2021, billed with code 0598T.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unstable to walk and need assistance to 
get back home. The Plan denied your request. The Plan says that your records do not show you require daily 
nursing or daily therapy services on an inpatient basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 26, 2020.
You asked the Plan to pay for this testing. 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. The Plan
requested a reopen and provided additional information. The Plan states the ordering physician confirmed this
test from another provider for which the claim was billed and paid by the Plan. The ordering physician
confirmed this testing was not ordered from the appealing provider. The Plan provided a copy of the paid claim
showing these services were paid to another provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment.
The Plan has provided conflicting information to show this service was ordered from and paid to a completely
different provider. Medicare rules for coverage of this testing were not met. Therefore, we decided that the Plan
does not have to pay for genetic testing provided to the enrollee on August 26, 2020.