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

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
(D0380) provided on June 28, 2022. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that this procedure was needed in 
order to establish care for your teeth underneath a bridge. The Plan denied your request. The Plan says benefits 
for this dental service are not available. 
 
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 cone 
beam computed tomography (CT) image capture (D0380) provided on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt and power footrest. 
 
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 power tilt and power footrests are covered when 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not reveal that 
you are unable to perform a functional weight shift, have intermittent catheterization for bladder management, 
or need a power seating system to manage increased tone or abnormal muscle stiffness (spasticity). The criteria 
for coverage are not met; therefore, the power tilt and power footrests are 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 a power tilt and power footrest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) and the office visit 
(99203) provided on March 4, 2022 and March 23, 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 these services are not a covered benefit under 
the enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (G0283) and the office visit (99203) provided 
on March 4, 2022 and March 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that additional therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there is insufficient clinical documentation with objective 
outcome measures indicating that the enrollee continues to make significant progress with continued therapy. 
Continued progress in terms of strengthening and endurance can be accomplished with the use of a home 
exercise program and the approved four additional visits of physical therapy should suffice to accomplish this. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 11 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service March 21, 2022. 
Therefore, we decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on 
March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on April 12, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 that your dental benefit was exhausted on date of service April 12, 2022. Specifically, on this day other 
dental services were provided to you. The Plan issued payment at the annual maximum amount of $1,000 for 
these services; therefore, the dental benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the core buildup, including any pins when required (D2950) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), 
localized delivery of antimicrobial agents (D4381 x4), periodontal scaling and root planing (D4342 x4), and 
inhalation of nitrous oxide (D9230) provided from April 11, 2022, through May 17, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were referred to the 
out-of-network provider by your general in-network dentist for treatment. The Plan denied your request. The 
Plan says your benefit for the limited oral evaluation, periodontal scaling and root planning, and inhalation of 
nitrous oxide has already been exhausted. Additionally, localized delivery of antimicrobial agents is not 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 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 limited oral evaluation, periodontal scaling and root planning, and inhalation of 
nitrous oxide was exhausted on date of service May 17, 2022. Additionally, localized delivery of antimicrobial 
agents is not a covered service. Therefore, we decided that the Plan does not have to pay an additional amount 
for a limited oral evaluation (D0140), localized delivery of antimicrobial agents (D4381 x4), periodontal 
scaling and root planing (D4342 x4), and inhalation of nitrous oxide (D9230) provided from April 11, 2022, 
through May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), prophylaxis - 
adult (D1110), and periodic oral evaluation - established patient (D0120) provided October 26, 2021. 
 
You asked the Plan to pay for the panoramic x-ray, dental cleaning and periodic oral exam. You say that the 
Plan should reimburse you for the dental expenses. The Plan denied your request. The Plan says you have 
exhausted 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. The Plan covers the panoramic 
x-ray, dental cleaning and periodic oral exam up to $1,000 every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 
dental allowance was applied to claims in 2021. Based on this information, we decided that the Plan's rules for 
coverage of the panoramic x-ray, dental cleaning and periodic oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), prophylaxis - adult 
(D1110), and periodic oral evaluation - established patient (D0120) provided October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an oral surgeon. 
 
You asked the Plan to pre-approve a consultation. You say that you need to have the growths removed so you 
can be fitted for dentures. The Plan denied your request. The Plan says that a consult with an oral surgeon is not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a consultation with an 
oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 Power wheelchair to include power tilt and several accessories (K0856, E2300, E2359, E2311, E2620, E2605, E1012, K0108, E0955, E1028, E2377, E1028, E2313, A9900, and E1002).
You asked the Plan to provide coverage for the requested power wheelchair and accessories. You say that the requested power wheelchair is medically necessary. The Plan denied your request. The Plan says the specific power wheelchair requested exceeds the enrollees needs for use in the home and some of the accessories requested (E2300) are not covered by Medicare under any circumstance. Maximus partially overturned the Plans denial stating the enrollee requires a power wheelchair for the diagnosis of spina-bifida. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan states the issue was not medical necessity for a power wheelchair, but that the appropriate power wheelchair was not requested by the provider for the enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for a K0856 Group 3 Power Wheelchair and the requested accessories. Medicare does not cover an E2300 power seat elevation system and related accessories under any circumstance. The records provided do not show the enrollee meets all the required criteria based on the Medicare guidelines. The records do not include a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical or occupational therapist or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The evaluator must not have any financial relationship with the supplier; and the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary. All the criteria required to provide coverage for the specific power wheelchair and accessories requested are not met. Therefore, we decided that the Plan does not have to provide coverage for a Group 3 Power wheelchair to include power tilt and several accessories (K0856, E2300, E2359, E2311, E2620, E2605, E1012, K0108, E0955, E1028, E2377, E1028, E2313, A9900, and E1002).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82565, 81003 and 83986 billed for date of 
service November 25, 2021. 
 
You asked the Plan to pay for procedure codes 82565, 81003 and 83986. You say that these services were 
medically necessary and are supported in the medical records provided. The Plan denied your request. The Plan 
says they have agreed to pay for the drug testing services; however, codes 82565, 81003 and 83986 were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 82565 is assay of creatinine, blood. We find that CPT 
code 82565 is not supported in the medical record. Specifically, the sample in this case was urine and not 
blood. In addition, the documentation indicates that this service was performed for specimen validity, which is 
not separately billable or payable. 
 
We have also confirmed that codes 81003 and 83986 are both column II codes to column I code 80307. These 
services have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 82565, 81003 and 
83986 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 82565, 
81003 and 83986 billed for date of service November 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from February 20, 2022, through March 8, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the skilled nursing facility care provided 
was not medically necessary. 
 
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 the continued SNF care. Our reviewer says 
that the SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services were not required. The enrollee was reported to be at her 
baseline functional level during the dates in question in this case. Additionally, as a practical matter, this 
enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. The services 
provided in this case from February 20, 2022, through March 8, 2022 appear to have been custodial 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from February 20, 2022, 
through March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low-profile push handle and rigidizer bar. 
 
You asked the Plan to pre-approve a low-profile push handle and rigidizer bar. You say that the requested low 
profile push handle and rigidizer bar are medically necessary. The Plan denied your request. The Plan says the 
requested low profile push handle and rigidizer bar are convenient items and 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 a low-profile push handle and rigidizer 
bar. Our reviewer says that the requested low profile push handle and rigidizer bar are convenient items and not 
medically necessary. Our physician reviewer found the accessories are not necessary for positioning, mobility, 
transfer, or skin protection. They are not medically necessary and therefore not covered per Medicare rules for 
durable medical equipment (DME) as the accessories must serve a medical purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a low-profile push handle and rigidizer bar have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a low-profile push handle and rigidizer bar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
September 27, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 99153 is not supported in the medical record. Specifically, the documentation submitted 
and claim form show that this procedure was performed in place of service 22 (On Campus-Outpatient 
Hospital). Payment for this service is included in payment to the facility and not separately reimbursable for 
this provider in this place of service. Based on this information, we decided that Medicare rules for coverage of 
the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
the moderate sedation services coded 99153 provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws (D0367), deep sedation/general anesthesiaeach 
subsequent 15 minute increment (D9223), the extraction of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), the incision and drainage of an abscess (D7521), an unspecified adjunctive 
procedure, by report (D9999), and the anesthesia (D9222) provided on January 20, 2022 and January 24, 2022. 
 
You asked the Plan to issue reimbursement for these dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit under your contractual policy.  
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367), 
deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223), the extraction of an erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210), the incision and drainage of an abscess 
(D7521), an unspecified adjunctive procedure, by report (D9999), and the anesthesia (D9222) provided on 
January 20, 2022 and January 24, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve 10 therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that the remaining 10 physical therapy visits requested 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that not 
all therapy goals have been met and appear to be reasonable with a time frame of the request thus 10 additional 
physical therapy sessions is 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 physical therapy visits.  
 
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.