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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional 
intraoral periapical x-ray (D0230) provided on February 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and additional intraoral periapical x-ray. You 
say that the provider stated multiple times that these services would be covered under your insurance. The Plan 
denied your request. The Plan says your benefits for these services have been satisfied and the frequency 
limitations have been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years. The record shows that you received a 
comprehensive oral evaluation (D0150) on January 24, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The contract also says that intraoral x-rays are limited to 1 procedure code per 
calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on February 24, 
2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and additional intraoral periapical x-ray (D0230) provided 
on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided by a participating 
provider on June 23, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says D2391 is not a covered 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 a resin-
based composite (D2391) provided by a participating provider on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330 and D2391) provided by a 
participating provider on February 9, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the maximum benefit allowance amount of $500 has already been 
met and 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to 
pay for a resin-based composite (D2330 and D2391) provided by a participating provider on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (root canal) (D3330) and a crown 
(D2751) for tooth #30. 
 
You asked the Plan to pre-approve a root canal and crown. You say that these services are necessary. The Plan 
denied your request. The Plan says these services 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 
endodontic therapy (root canal) (D3330) and a crown (D2751) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and extraction to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist referred you to an oral 
surgeon. You say that the cap came off your tooth in April 2022. You also say that your regular dentist cannot 
remove your tooth due to potential problems caused by a medication you are currently taking. The Plan denied 
your request. The Plan says services received by an oral surgeon are not covered. The Plan also says services 
must be performed by a participating general dentist. 
 
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 services are not among 
those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does 
not have to pre-approve a consultation and extraction to be performed by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81292) provided on August 3, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical necessity. The Plan denied your request. The Plan says the claim has not been billed as required 
by Medicare billing regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81206, 81292) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray, office visit, and physical therapy services provided 
from October 7, 2021, to December 27, 2021. 
 
You asked the Plan to pay for the x-ray, office visit, and physical therapy services. You say that the plan has 
paid for previous chiropractic services. The Plan denied your request. The Plan says the chiropractic 
manipulative treatment (98940) has been paid. The Plan also says that the x-ray, office visit, and physical 
therapy services remain denied as non-covered chiropractic services. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray, office visit, and physical therapy services provided from October 7, 
2021, to December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010), precision attachments 
(D5862), and an implant/abutment supported lower denture (D6111). 
 
You asked the Plan to pre-approve dental implant services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services (implant services) are not covered by the Plan's 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 
dental implants (D6010), precision attachments (D5862), and an implant/abutment supported lower denture 
(D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer (D2962) provided on November 18, 2021. 
 
You asked the Plan to pay for the labial veneer. You say that you would have preferred to have a cap to protect 
the front and back of the tooth, but the dentist said you needed a veneer on the tooth. You also say that when 
you contacted the Plan you were advised that you had $2,000 for the 2021 plan year, and neither agent said the 
repair would not be covered. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you contacted the plan twice before this date of service and no 
inaccurate information was provided. 
 
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 labial 
veneer (D2962) provided on November 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary as 
the enrollee presented with respiratory failure, mental status changes and pneumonia and is being treated with 
inhaled medication and antibiotics through a tube. The Plan denied your request. The Plan says Long-Term 
Acute Care admission is not medically necessary because the enrollee can continue to receive care in the 
current inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH care is not considered medically reasonable and necessary in 
this case.  
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing (NGS) panel provided 
on December 20, 2021. 
 
You asked the Plan to pay for the NGS panel. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include testing for the FANCC gene 
are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the NGS panel rendered included 
testing for the FANCC gene. This means the entire panel is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the NGS panel have not been met. Therefore, we decided that the Plan does not have to pay for the next generation sequence testing (NGS) panel 
provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99238 provided on July 4, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their 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. 
 
In this case, the CPT Code Manual definition of code 99238 is hospital discharge day management; 30 minutes 
or less. 
 
 We find that CPT code 99238 is not supported in the medical record. Specifically, the documentation does not 
include discussion of the hospital stay or after-care instructions to support the hospital stay services billed. 
Based on this information, we decided that Medicare rules for coverage of the hospital discharge day 
management services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management services coded 99238 provided on July 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for cardiovascular procedures, echocardiography procedures and 
anesthesia for intrathoracic procedures provided on January 6, 2022. 
 
You asked the Plan to pay for cardiovascular procedures, echocardiography procedures and anesthesia for 
intrathoracic procedures. The Plan denied your request. The Plan says that the precertification entity was not 
contacted for precertification. 
 
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. The Plan has not provided us with the Plans rule to support this denial. 
Therefore, we decided that the Plan has to pay for cardiovascular procedures, echocardiography procedures and 
anesthesia for intrathoracic procedures provided on January 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908-26 and 95886-26 (x2) billed for date 
of service October 20, 2021. 
 
You asked the Plan to pay for procedure codes 95908-26 and 95886-26 (x2). You say that the medical records 
support payment of this claim in full. The Plan denied your request. The Plan says procedure codes 95908-26 
and 95886-26 are not supported by the medical record. For code 95908-26, the technical report did not include 
documentation of 3-4 nerve conduction studies. For code 95886-26 (x2), the technical report did not include 
documentation of a complete needle electromyography. 
 
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 95908 is Nerve conduction studies; for 3-4 studies. The 
CPT Code Manual definition of code 95886 is complete needle electromyography, per each extremity with 
related paraspinal areas when when performed, done with nerve conduction, amplitude and latency/velocity 
study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure). 
 
We asked our coder 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 procedure codes 95908-26 and 95886-26 (x2). Our reviewer 
says that procedure codes 95908-26 and 95886-26 (x2) are not supported in the medical record. Our reviewer 
found for code 95908, the procedure report describes pedicle screw stimulation, which would not be reported 
with nerve conduction studies which measure amplitude and latency/velocity. Therefore, this procedure cannot 
be verified. For code 95886, this procedure per CPT code description is "done with" nerve conduction 
studies.  In this case, nerve conduction studies cannot be verified, and therefore this procedure would not be 
covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95908-26 and 95886-26 (x2) have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95908-26 and 95886-26 (x2) billed for date of 
service October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330, D2392) and intraoral 
periapical X-rays (D0220, D0230) provided on November 24 and December 15, 2021. 
 
You asked the Plan to pay for resin-based composites and intraoral periapical X-rays. You say that the services 
at issue were a necessity for your care. The Plan denied your request. The Plan says rules for payment for 
dental services have not been met. 
 
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 resin-based 
composites at a rate of one procedure code per calendar year.  
 
We looked at the file and Medicare rules. The Plan has documented that a prior claim for a resin-based 
composite has been processed and paid. You have met the frequency limitation for resin-based composites. 
Furthermore, though the Plan offers a dental benefit in excess of Medicare coverage, intraoral periapical X-rays 
are not among the services covered under this benefit. Based on this information, we decided that the Plan's 
rules for coverage of resin-based composites and intraoral periapical X-rays have not been met. Therefore, we 
decided that the Plan does not have to pay for resin-based composites (D2330, D2392) and 
intraoral periapical X-rays (D0220, D0230) provided on November 24 and December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory 
(E0673) provided on August 18, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and accessory. You say that these items were 
medically necessary. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. If the base PCD is not covered, related accessories are not eligible for 
reimbursement.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and accessory (E0673) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided October 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150) provided October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services with the original diagnosis-related group (DRG) 
submitted. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their 
decision. The Plan denied your request. The Plan says that the DRG billed is not supported by the 
documentation. 
 
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. Review of the file shows that medical records were not provided to Maximus for 
review. Without these required documents, the Plan's argument that the DRG is not supported is not valid. 
Therefore, we decided that the Plan has to pay for the inpatient services with the original diagnosis-related 
group (DRG) submitted.  
 
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.