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

 
We decided that the Plan does not have to pre-approve anesthesia. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 
anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the power options are medically 
necessary for the enrollee. The Plan denied your request. The Plan says although there are three approved 
power options/features on this wheelchair, there is not a medical need to control these power options/features 
through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records document that the enrollee has 3/5 upper extremity strength, and he 
is modified independent with feeding (requires extra time) and grooming/hygiene (while seated), thus 
indicating he has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical connection between the wheelchair controller and two or more 
motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy visits. 
 
You asked the Plan to pre-approve additional occupational therapy visits. You say that you want the Plan to 
approve the services. The Plan denied your request. The Plan says they will need to reassess after the currently 
allowed sessions are complete. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 additional occupational therapy visits 
have been met. The Plan has approved more than the 12 sessions noted in your appeal request, and that until 
records from the approved sessions are available, a determination on whether more sessions are medically 
necessary cannot be made. Therefore, we decided that the Plan does not have to pre-approve additional 
occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric wheelchair. 
 
You asked the Plan to pre-approve an electric wheelchair. You say that you urgently require a wheelchair due 
to your medical condition. You say that you have been in the hospital for many days and have difficulty 
walking. You say that your left leg is not able to ambulate. The Plan denied your request. The Plan says there 
were no notes submitted showing that you have a mobility limitation. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 an electric wheelchair have been met. 
Specifically, there were no medical records submitted to show that the requested item is medically necessary. 
The Plan showed that they made reasonable attempts to obtain medical records. Without this necessary information, we are unable to confirm that Medicare criteria for coverage have been met. Therefore, we 
decided that the Plan does not have to pre-approve an electric wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. Your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health 
care, or in a long-term care 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. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Homologous Recombination Deficiency (HRD)
testing provided to the enrollee on May 3, 2022.
You asked the Plan to pay for the testing. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says that the specimen was collected during an outpatient
encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of
service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An
independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen
was not collected in an independent laboratory.
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 code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Homologous
Recombination Deficiency (HRD) testing provided to the enrollee on May 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit (99212), manual therapy (97140), and the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072) provided on June 3, 2022.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that that these services are not covered by your Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the office visit (99212), manual therapy (97140), and the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072) provided on June 3, 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.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #19. 
 
You asked the Plan to pre-approve the dental service. You say that you need the tooth saved and do not want to 
have it pulled. The Plan denied your request. The Plan says that the tooth has a lot of missing cavities and can 
no longer be fixed with a filling. 
 
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 dental 
service 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 pre-approve the dental service. Our reviewer says 
that the crown for tooth #19 is medically necessary. Our physician reviewer found that the documentation 
indicates that tooth #19 has a large restoration and a fractured lingual surface which is not visible on the 
radiograph but was indicated in the narrative. It is medically reasonable and necessary to restore tooth #19 with 
a crown restoration to provide good masticatory function and provide strength to the coronal surface. 
 
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 the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #19.  
 
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 genetic testing provided on July 21, 2022, billed with 
codes 81321, 81307, 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 21, 2022, billed with codes 81321, 81307, 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial lower denture (D5821) provided on 
September 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you got the extra dental policy so it would cover 
your dentures. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the interim partial lower denture is not covered by 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
partial lower denture (D5821) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4267) and a bone replacement 
graft (D7953) for tooth #30 provided on September 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were necessary. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the guided tissue 
regeneration and the bone replacement graft are not covered by 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 guided 
tissue regeneration (D4267) and a bone replacement graft (D7953) for tooth #30 provided on September 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the solid tumor testing (81479) provided to the enrollee on December 22, 2021.
You asked the Plan to pay for the testing. You say that this testing was medically necessary and is supported in the medical record. The Plan denied your request. The Plan says that the specimen was collected during an outpatient encounter.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the solid tumor testing (81479) provided to the enrollee on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Walk Easy Cuff Crutch (E0110). 
 
You asked the Plan to pre-approve a Walk Easy Cuff Crutch. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested provider is not a participating provider with Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve a Walk Easy Cuff Crutch (E0110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37233 and 75710 billed for date of service 
August 27, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 37233 is revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty 
within the same vessel, when performed (List separately in addition to code for primary procedure). We find 
that CPT code 37233 is not supported in the medical records. The records do not show that the billed code 
accurately describes the services provided.  
 
The CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological supervision 
and interpretation. We find that CPT code 75710 is inclusive to code 37229. The medical records provided do 
not show that the service billed with the -59 modifier is a distinct procedural service. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 37233 and 75710 billed for date of service 
August 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of bone marrow aspirate is 
considered experimental in nature. More research is needed to support its use. The bone marrow aspirate is 
therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air fluidized bed (E0194). 
 
You asked the Plan to pre-approve an air fluidized bed. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an air-fluidized bed is covered only if specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an air fluidized bed. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not include 
a recent comprehensive assessment by the treating practitioner. There is no indication that she has any active 
pressure injuries or has failed conservative 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 an air fluidized bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an air fluidized bed (E0194).