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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the panoramic 
radiographic image (D0330), and extractions (D7140 and D7210) for tooth #3, #4, #5, #6, #7, #8, #9, #10, #12, 
#14, #15, #19, #20, #22, #23, #24, #25, #26, #27, #30 provided by an out-of-network provider on December 5, 
2022, and December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the oral surgery was medically necessary for 
your heart surgery. The Plan denied your request. The Plan says your benefit for the panoramic radiographic 
image and extractions has already been exhausted and you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. Also, the denial 
of payment for the limited oral evaluation is correct because it 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on the date of service of September 7, 
2022, and your benefit for the extractions was exhausted on the date of service of December 9, 2022. The 
limited oral evaluation is not covered under the Plans dental benefit. You have also been asked to pay the 
difference between the out-of-network providers charges and the Plans payment for the extractions. 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 pay for a limited oral evaluation (D0140), the panoramic radiographic image 
(D0330), and extractions (D7140 and D7210) for tooth #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #19, #20, 
#22, #23, #24, #25, #26, #27, #30 provided by an out-of-network provider on December 5, 2022, and 
December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12011 billed for date of service October 11, 
2022. 
 You asked the Plan to pay for procedure code 12011. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 12011 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 12011 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 12011 billed for date of service October 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284-57 billed for date of service January 
24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the service is not considered a component of the 
procedure. The Plan denied your request. The Plan says the code is included when billed the same day as the 
minor procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99284-57 was billed with minor procedure code 28660. CPT code 99284 was not billed 
with a valid modifier for a separately identifiable service from a minor procedure. 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 code 99284-57 billed for date of service January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the items were issued for use during surgery. 
The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The claim information shows the services were provided at an outpatient 
hospital facility. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on September 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that a SNF admission is necessary because you are 
currently using a walker and are at a high risk for fall and are having verbal and comprehensive aphasia issues. 
The Plan denied your request. The Plan says you do not meet the criteria for a SNF admission. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF care was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. 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.
Based on the medical records provided, you had severe weakness and issues with fatigue, making no progress with physical therapy services provided in the hospital. The records do not show an ability to participate in an intensive rehabilitation therapy program of at least three hours of therapy per day at least five days per week. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, medical records were not provided for this case. 
The record shows that the Plan made multiple attempts to obtain this information, but it was not received. 
Without medical records, we are unable to determine if you meet all of the criteria for coverage. Specifically, 
the provider's attestation confirms that you do not meet all the required criteria for coverage. Therefore, we 
decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve thermal facet joint RFA. 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 repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and ADLs as compared to baseline measurement using the same scale.  
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 thermal facet joint RFA. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found coverage criteria require 
repeating the diagnostic blocks before repeating the RFA if more than 2 years have passed since the initial RFA 
as in this case. Therefore, the request is deemed not medically reasonable and necessary at this point in 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 thermal facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal facet joint radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service November 5, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 
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, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service November 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for code 26080 for "arthrotomy, with exploration, drainage, or
removal of loose or foreign body; interphalangeal joint" billed to the enrollee for May 18, 2022.
You asked the Plan to pay for this service. You say that the Plan should pay this service. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is whether the medical records
support the billing of code 26080 for arthrotomy, with exploration, drainage, or removal of loose or foreign
body; interphalangeal joint. The Maximus Physician Reviewer determined that the enrollee was being treated
for idiopathic chronic gout of the left hand with tophus (tophi) and underwent excision of gouty tophi on
August 5, 2022.
The Plan argues codes 24105-LT and 26080-59-F2 were approved. Code 26080-59-F1 was denied as "Not
Supported in the Medical Records Submitted." The Plan states, "The operative report did not include
documentation of an arthrotomy of each interphalangeal joint with exploration, drainage, or removal of loose or
foreign body; therefore, this code cannot be verified." The Plan is correct in this case. The documentation in
the Operative Note dated August 5, 2022, does not document the description of code 26080 for arthrotomy,
with exploration, drainage, or removal of loose or foreign body, interphalangeal joint, for the index finger.
Rather, the documentation supports that MP joint of the index finger was operated on.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pay for the billing of CPT 26080: Arthrotomy, with exploration, drainage, or removal of loose or
foreign body; interphalangeal joint billed to the enrollee for May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on October 19, 2022. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic laboratory 
testing provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation mileage. 
 
You asked the Plan to pre-approve the additional transportation mileage. You say that you need to attend an 
appointment that is over 50 miles. The Plan denied your request. The Plan says the service exceeds the 50-mile 
limit. 
 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 50 miles per trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have asked the Plan to cover an additional 27 miles which is not a covered benefit for routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve the additional transportation 
mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service February 23, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that the service was necessary to the enrollee's 
care. The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 
99222. 
 
 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, we have confirmed that code 99232 is a column II code to column I code 99222 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 
billed for date of service June 15, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for continued SNF care. You say that at the time of the appeal, SNF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file. At issue is coverage for continued SNF services. The Maximus Physician Reviewer determined that no SNF records were submitted for review. "No physical or occupational therapy records have been submitted for review. Therefore, the health plan has failed to support its denial." The Plan has requested a reopen and submitted additional clinical records. Included is a Physical Therapy Treatment Encounter Note(s) dated documenting the enrollee ambulated 382 ft, 330 ft, and 440 ft with a 2 wheeled walker. The enrollee was admitted to the hospital on September 30, 2022. The enrollee was having visual and auditory hallucinations of unclear etiology, anemia, mild hypokalemia, and dehydration with urine ketones. Imaging of the head showed no acute changes. Neurology determined that the symptoms were possibly medication-related and was also suspicious that they could be related to senile dementia. Further cognitive evaluation as an outpatient was recommended. On October 2, 2022, the enrollee denied any hallucinations. A small dose of Donepezil was to be started. The enrollee was admitted for SNF level services on October 3, 2022. On October 20, 2022, the enrollee signed a notice on non-coverage advising that services would be terminated on October 22, 2022. The additional documentation provided supports that the enrollee no longer needed skilled therapy services on a daily inpatient basis. Therefore, continued SNF services were 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 SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF) care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hydromorphone injections (J1170), drugs (J3490), and 
home infusion therapy services (S9328) provided from February 1, 2022 to August 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the Hydromorphone injections, drugs, and home infusion therapy services. You 
say that you would like these claims to be approved for payment. The Plan denied your request. The Plan says 
the enrollee's plan excludes coverage for these out-of-network services.  
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 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 Hydromorphone injections (J1170), drugs 
(J3490), and home infusion therapy services (S9328) provided from February 1, 2022 to August 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics and two retainer crowns. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on authorization number A0221028000074. 
Therefore, we decided that the Plan does not have to pre-approve two pontics and two retainer crowns.
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 require 3 hours of therapy and family training 
prior to returning home. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met in other settings. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.