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

 
We decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect) (D5750) 
and reline complete mandibular denture (indirect) (D5751). 
 
You asked the Plan to pre-approve a complete upper and lower denture reline. You say that the reline is 
medically necessary and should be covered. The Plan denied your request. The Plan says this service is not 
covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
reline complete maxillary denture (indirect) (D5750) and reline complete mandibular denture (indirect) 
(D5751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
December 1, 2021. 
 
You asked the Plan to pay for bitewings. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says the benefit limit for D0274 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. The Plan covers bitewings 
once per year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0274 as provided on May 27, 
2021. Based on this information, we decided that the Plan's rules for coverage of bitewings have already been 
met. Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided by a 
participating provider on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on November 11, 2021. 
 
You asked the Plan to pay for the intraoral x-ray. You say that you were told x-rays were covered by your Plan 
and you would not be responsible for these charges. The Plan denied your request. The Plan says this type of x-
ray is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-ray (D0220) provided on November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the item is necessary. The 
Plan denied your request. The Plan says Medicare does not cover this item. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the power seat elevation system have not been met. The rules say 
that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they 
are not primarily medical in nature. If a wheelchair has an electrical connection device described by code 
E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing 
feature, it will be denied as non-covered. Therefore, this item is not covered. Therefore, we decided that the 
Plan does not have to pre-approve the power seat elevation system (CPT code E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on May 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 is 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 99239 is hospital discharge day management; more than 
30 minutes. 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of discharge day management services. 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 pay for the hospital discharge services rendered on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (CPT code(s): 87486, and 87581) provided on 
August 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the place of service on the CMS-1500 form line 24B must reflect the location 
of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. The Plan overturned other laboratory services that were billed exactly 
like the denied services; therefore, the Plan has to pay for the services. Therefore, we decided that the Plan has 
to pay for the laboratory services (CPT code(s): 87486, and 87581) provided on August 25, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve add tooth to partial denture (D5650) for three teeth. 
 
You asked the Plan to pre-approve denture repairs. You say that you need to have additional teeth extracted, 
and these services are necessary to keep your current denture usable. The Plan denied your request. The Plan 
says adding teeth to a denture is considered a denture repair service. Denture repairs are not covered by your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve add 
tooth to partial denture (D5650) for three teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (code D4342) you had 
on November 19, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that this cleaning was for the 
right side bottom of your mouth, so this should be covered. The Plan denied your request. The Plan says you 
had already exhausted your benefit for this service when you received this same service (code D4342) on 
August 6, 2021. 
 
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. Your contract says that 
periodontal scaling and root planing is only covered once every three years. 
 
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 
periodontal scaling and root planing (code D4342) you had on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with 
interpretation (D0367) provided on September 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have been suffering with jaw pain for over 
11 years. You say that as a result your dentist referred you for this service. You also say that you feel this 
should have been submitted to your medical coverage. The Plan denied your request. The Plan says cone beam 
CT capture with interpretation is not listed as a covered service. 
 
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 cone beam CT capture with 
interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the cone beam computed tomography (CT) capture with interpretation (D0367) provided on 
September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy (D7286) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve an incisional biopsy. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy (D7286) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed to the enrollee for January 4, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial
administratively for insufficient information in the case file. The Plan requested a reopen and provided the
required information.
The Plan states that a TENS device including supplies is not a Medicare covered benefit based on the diagnosis
codes reported. The Plan states a pneumatic compression is only covered for the treatment of chronic venous
insufficiency with venous stasis ulcers, and refractory lymphedema. Finally, the Plan states that vitamin
injections into the nerve and musculoskeletal structures are not a Medicare covered service.
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 codes and when necessary,
provide documentation to show the services billed met the Medicare coverage criteria requirements.
The diagnoses codes are G89.4 Chronic pain syndrome, M79.671 and M79.672, pain in right foot. The codes
billed do not support the services that are covered by Medicare. Additional references for proper billing
procedures are seen in the Medicare National Coverage Determination for Transcutaneous Electric Nerve
Stimulation (TENS) for neuromuscular reconditioning (160.12) and supplies (160.13), the Medicare National
Coverage Determination (NCD) for Pneumatic Compression Devices (280.6) and the Medicare Benefit Policy
Manual, chapter 15.
As the Medicare coverage criteria for the services billed were not met at the time of service, the Plan does not
have to pay for any of the services billed to the enrollee for January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a K0806 power mobility device and accessories for
the enrollee.
You asked the Plan to provide coverage for a K0806 power mobility device and accessories. You say that the
requested power mobility device and accessories are medically necessary. The Plan denied your request. The
Plan says Medicare coverage criteria for the requested equipment are not met. We overturned the Plans
denial stating this equipment is medically necessary. The Plan requested a reopen and stated that the issue was
not medical necessity but that the power mobility device requested has capabilities not required for use in the
home and is not covered by Medicare.
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.
The rules specifically state a K0806 power mobility device has capabilities not required in the home and is not
covered by Medicare. Although this type of equipment may be helpful to the enrollee, neither Medicare nor the
Plan covers this equipment. It should be noted the Plan was willing to work with the ordering physician and the
provider to request a more appropriate power mobility device for the enrollee that is covered by Medicare.
Therefore, we decided that the Plan does not have to provide coverage for a K0806 power mobility device and
accessories for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial for
insufficient claim information in the case file. The Plan requested a reopen and provided additional claim
information. The claim shows the place of service code 21 for inpatient services was billed, rather than the
correct place of service code 22 or 24 for outpatient services.
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 place of service code.
In this case, the claim submitted could not be paid as billed due to an error with the place of service code.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 12,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from
November 8, 2020, to December 7, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says as of the dates in question, the enrollees care was custodial in nature.
We administratively overturned the Plans denial because the case file lacked a valid notice of noncoverage.
The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. 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. The
medical records provided show that as of November 5, 2021, which is the day notice of non-coverage was
given, the enrollee no longer needed daily skilled nursing or daily skilled therapy services at an inpatient level
of care in a facility setting. Therefore, we decided that the Plan does not have to pay for skilled nursing facility
services provided to the enrollee from November 8, 2020, to December 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for monitoring services provided to the enrollee on January 14, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. We overturned the Plans denial for
insufficient claim information. The Plan requested a reopen and provided additional claim information. The
records show this procedure was authorized for an outpatient surgery and this claim was billed as inpatient
services. This claim denied for an inappropriate place of service code.
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 place of service code. In this case,
this claim was submitted with an inappropriate place of service code. Therefore, we decided that the Plan does
not have to pay for monitoring services provided to the enrollee on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 4 epidural steroid injections for the enrollee.
We note that 2 injections were approved by the Plan prior to our original decision.
You asked the Plan to pre-approve 4 injections. The Plan denied your request. The Plan says Medicare
coverage criteria are not met for 4 injections. We partially overturned the Plans denial and stated that 2 of
the 4 injections requested were able to be approved. The Plan requested a reopen and stated that the Plan
approved 2 injections prior to the IRE's decision, which matches the decision made by the IRE reviewer.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover 4 injections in
one treatment. Our reviewer confirmed that 4 injections do not meet Medicare coverage guidelines. Our
physician reviewer found only two injections were found to meet the required criteria. This was also the
original decision made by the Plan. Therefore, we decided that the Plan does not have to pre-approve 4 epidural
steroid injections total for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for the inpatient hospital care from May 25, 2021, to May 26, 2021.
You asked the Plan to pay for inpatient hospital care. You say that continued inpatient care was necessary as
the enrollee was not ready to go home. The Plan denied your request. The Plan says the enrollee no longer met
the criteria for inpatient care and was given notice of non-coverage. The Plan also noted that skilled nursing
facility services were requested and denied as the enrollee did not meet the required criteria for those services.
We overturned the Plans denial due to a lack of medical records in the case file. The Plan requested a
reopen and submitted medical records.
The Plan is correct in this case. Medicare covers inpatient hospital care that is medically necessary. As of May
24, 2021, the medical records show the enrollee no longer required an inpatient level of care. The medical
records also show the family did not support the enrollee going home and sought social placement. Medicare
does not pay for inpatient care for the purpose of finding social placement. The records show the enrollee was
ready for discharge and had been given notice by the Plan that coverage for inpatient care would end. The
records show the enrollee was denied skilled nursing facility placement. Based on this information, Medicare
rules for coverage of inpatient hospital care after May 24, 2021, were not met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital care provided from May 25, 2021, to May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts (D6104) and implants (D6010) to be provided by a participating provider.

You asked the Plan to pre-approve bone grafts and implants. You say that these services meet the criteria needed for these services. The Plan denied your request. The Plan says in order for this to be approved the member must only be missing 1 tooth in this part of the mouth. The records show that the member is missing more than 1 tooth in this part of the member's mouth.

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. The Plan covers bone grafts and implants 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 bone grafts and implants. Our reviewer says that the documentation provided does not meet the criteria for coverage for bone grafts D6104 and implants D6010 for areas #3 and #5. Our physician reviewer found the documentation indicates multiple maxillary missing teeth bilaterally. Restoring the missing teeth bilaterally can be accomplished be other means.

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 bone grafts and implants have not been met. Therefore, we decided that the Plan does not have to pre-approve bone grafts (D6104) and implants (D6010) to be provided by a participating provider.

The original decision letter was amended to include specific details from the contract regarding the dental benefit in the Medicare rules section which was omitted in error.