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

 
We decided that the Plan does not have to pre-approve sinus augmentation with bone or bone substitutes 
(D7951 x 2). 
 
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 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 sinus 
augmentation with bone or bone substitutes (D7951 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from November 25, 2022, to November 
30, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing 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 pay for SNF care provided from November 25, 2022, to November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF 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 stated that Maximus did not apply the correct criteria. The Plan noted that the medical records do not support all required criteria for an inpatient rehabilitation level of care were met.
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, at the time of the appeal, the enrollee did not require daily skilled nursing at daily skilled therapy services at an IRF level of care. The records also do not indicate the enrollee would be able to participate in the required therapy schedule provided at an IRF. Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a pelvic exam and pap smear provided on July 11, 2022.
You asked the Plan to pay for these services. You say that this exam should be paid by the Plan. The Plan denied your request. The Plan says this exam is only covered every 24 months and your last exam was June 22, 2021, which is less than 24 months. Maximus overturned the Plans denial for insufficient information in the case file to show this service was exhausted at the time of service. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says a pay pap test and pelvic exams are covered every 24 months unless you are high risk. The records submitted do not show that you are high risk. The records show you had an exam on June 22, 2021, and then July 11, 2022, thirteen months later. Therefore, we decided that the Plan does not have to pay for a pelvic exam and pap smear provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for Medicare Part B drugs and
administration charged for services provided on September 29, 2020.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 20% coinsurance for
Medicare Part B drugs to include cost for administration.
You have been asked to pay 20% coinsurance for this cost share. This item/service falls within the for
Medicare Part B drugs to include cost for administration 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 waive or reduce the cost share for Medicare Part B drugs
and administration charged for services provided on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX-Scc test provided to the enrollee on August 8, 2022.
You asked the Plan to pay for the testing. You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered.
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, and approval process.
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDX-Scc test provided to the enrollee on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay additional reimbursement for dental services ($1788) provided on July 6, 2022.
You asked the Plan to pay additional reimbursement for dental services. The Plan denied your request. The Plan says the $1500 benefit was exhausted with these services. Maximus overturned the Plans denial. The Plan requested a reopen and noted the dental claim was filed was for $3576.The allowed amount was $3288. The Plan paid the provider $1500 leaving a balance of $1788.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The claim submitted was payable at $3288. The Plan paid the maximum dental benefit of $1500. This means the whole of your benefit was exhausted and the balance would be your responsibility. Therefore, we decided that the Plan does not have to pay additional reimbursement for dental services ($1788) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided to the enrollee on June 22, 2022.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says that the enrollee was enrolled in Hospice during the date of service.
Maximus overturned the Plan's denial. The Plan requested a reopening based on incorrectly stating the enrollee's Hospice start date.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided to the enrollee on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the ability drive interface and Permobil/rnet alternative drive port.
You asked the Plan to provide coverage for this accessory. You say that at the time of the appeal this accessory was medically necessary. The Plan denied your request. The Plan says this accessory exceeds your needs in the home and is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria.
The Plan is correct in this case. 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. Deluxe accessories or accessories that exceed your medical needs for the purpose of convenience are not covered. The ability drive interface and Permobil/rnet alternative drive port may be beneficial for your use but exceeds your needs in the home.
Neither Medicare nor the Plan covers this accessory. Therefore, we decided that the Plan does not have to provide coverage for the ability drive interface, Permobil/rnet alternative drive port.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) on tooth #30 provided on July 22, 2022.
You asked the Plan to pay for the crown. You say that the dental office should have determined if the procedure was covered before providing the service. 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 Plan's 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 date of service December 27, 2021.
Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #30 provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the dental services provided on May 17, 2022.
You asked the Plan to pay more for the dental services. You say that you believe you should receive more reimbursement. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider.
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.
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's payment. 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 more for the dental services provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refractive services provided on September 6, 2022.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this service was only covered once per year during a routine eye exam. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the Plan offered a supplement vision benefit that stated an eye refraction is covered as a part of one routine vision exam per year. The Plan noted the medical records provided do not indicate that the eye refraction was provided as a part of a routine eye exam.
The Plan is correct in this case. Medicare does not cover refraction services. The Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refraction once per year during a routine vision exam. The records show the services on September 6, 2022, were not a routine vision exam. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for refractive services provided on September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on August 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the lab orders and results support payment for 
the services rendered. The Plan denied your request. The Plan says the testing does not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, there are insufficient medical records that show specific clinical indications and reasons for 
performing the panel testing. Also, the panel testing was not billed with a single code as required. 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 the respiratory pathogen panel provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350 x4), and panoramic radiographic image (D0330) provided on October 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not have these services rendered. The 
Plan denied your request. The Plan says your benefit for the panoramic radiographic image (D0330) 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 panoramic radiographic image (D0330) was exhausted on October 7, 2022. 
Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-
orally or extra-orally (D0350 x4), and panoramic radiographic image (D0330) provided on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve deep sedation (D9222 and D9223). We decided that the Plan does 
not have to pre-approve therapeutic parenteral drug (D9610).  
 
You asked the Plan to pre-approve deep sedation (D9222 and D9223) and therapeutic parenteral drug (D9610). 
You say that you were referred to an oral surgeon who could perform extractions under sedation due to a heart 
condition. You say you are in severe pain and need this tooth removed. The Plan says that benefits are not 
available when performed due to patient management/apprehension. 
 
We decided that the Plan has to pre-approve deep sedation (D9222 and D9223). 
 
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 deep sedation (D9222 and D9223). Our 
physician reviewer found that you have a heart condition, supraventricular tachycardia, which can be triggered 
by anxiety or stress. Due to the stress and anxiety of a surgical procedure, it is medically reasonable and 
necessary to perform the surgical procedure using sedation.   
 
We also decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610). 
 
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, therapeutic parenteral drug (D9610) is 
not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
parenteral drug (D9610). 
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 36415, 49585, 80053, 
85027, C1781, J0690, J1100, J2250, J2405, J2704, J3010 and J7030. We decided that the Plan does not have to 
pay for the service described by procedure code 85004.  
 
You asked the Plan to pay for outpatient services provided from July 27, 2022, to July 29, 2022. You say that 
these services were necessary and were reported appropriately. The Plan says that the payment for code 85004 
would be included in the payment for code 85027. These codes are not allowed to be billed together, even with 
an appropriate modifier. This claim line is denied, and due to this OCE error, the rest of the claim is denied as 
well. 
 
We decided that the Plan has to pay for the services described by procedure codes 36415, 49585, 80053, 
85027, C1781, J0690, J1100, J2250, J2405, J2704, J3010 and J7030.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan cites the I/OCE edit error as the reason for the denial of the 
entire claim. However, for the edit applied in this case, the disposition is to reject only the offending claim line. The remainder of the claim may be processed as usual. The Plan has provided no other reason for denial of 
these services. Therefore, we decided that the Plan has to pay for the services described by procedure codes 
36415, 49585, 80053, 85027, C1781, J0690, J1100, J2250, J2405, J2704, J3010 and J7030.  
 
We also decided that the Plan does not have to pay for the service described by procedure code 85004. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that when the column II code 
of a code pair that is not allowed by NCCI even if an appropriate modifier is present is reported, the line is 
rejected. 
 
In this case, we have confirmed that code 85004 is a column II code to column I code 85027 with a modifier 
indicator of 0. The column II code is therefore not payable, even if an appropriate modifier is reported. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for the service described by procedure code 85004. 
 
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 procedure codes 87150-XU and 87801 billed for date of 
service October 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the specimens are received by providers who 
have performed biopsies. The Plan denied your request. The Plan says the codes remain not supported. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. We find that CPT code 87801 is not supported. 
Neither the claim nor the medical records show indicates the specific organisms that coincide with the billed 
code. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. 
 
We have confirmed that code 87150 is a column II code to column I code 87500. Code 87150 was billed with 
the XU modifier. The records do not show that the service was distinct and did not overlap the usual 
components of the main service. Code 87150 has not been billed with an appropriate modifier to bypass the 
edit. Based on this information, we decided that the Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150-XU and 87801 billed for date of service 
October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44180 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 44180. You say that the claim was submitted correctly. The Plan 
denied your request. The Plan says no modifiers are allowed with this code pair. 
 
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 44180 is a column II code to column I code 43848 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 44180 
billed for date of service October 12, 2022.