Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 11, 
2022, to April 30, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no 
nursing services which would be considered skilled services by Medicare.  
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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 11, 2022, to April 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction of tooth #30 (D7210). 
 
You asked the Plan to pre-approve an extraction. You say that you did not have a tooth pulled, and this has 
been billed incorrectly. The Plan denied your request. The Plan says an extraction (D7210) is not covered by 
your dental 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 an 
extraction of tooth #30 (D7210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 4, 2021, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically reasonable 
and necessary. The Plan denied your request. The Plan says this test was not medically necessary and was not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 4, 2021, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81317, 81401, 81194 and 81309.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the weight management classes (S9449) purchased between 
September 21, 2021, to December 23, 2021. 
 
You asked the Plan to pay for the weight management classes. You say that this is a benefit you are given. The 
Plan denied your request. The Plan says it was determined these services were received in an outpatient setting 
and is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that the weight management program should provide 
structured lessons on a weekly basis that are tailored to the beneficiaries personal goals. The rules also say that 
the program should support self-monitoring of eating and physical activity as well as offer regular feedback 
from a counselor on goals, progress, and results  
 
We looked at the file and Medicare rules. The contract clearly states that intensive counseling to help you lose 
weight is covered if you get it in a primary care setting. The record shows that the classes you participated in 
were provided by a team in a classroom, not in a primary care setting. Based on this information, we decided 
that Medicare rules for coverage of the weight management classes have not been met. Therefore, we decided 
that the Plan does not have to pay for the weight management classes (S9449) purchased between September 
21, 2021, to December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that you are requesting 
reconsideration of the denial for the requested device. The Plan denied your request. The Plan says the 
requested device does not meet the requirements for approval. 
 
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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested device is not reasonable and necessary for the diagnosis 
or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is 
not known to be effective, based on scientific evidence, professional standards and expert opinion, in 
improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific 
evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term 
outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient 
evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two prefabricated posts and cores in addition to crowns 
(D2954 x2) provided on May 31, 2022. 
 
You asked the Plan to pay for the prefabricated posts and cores. You say that you feel that the Plan should 
cover at least 30 percent of these services because you are enrolled in the enhanced dental coverage. The Plan 
denied your request. The Plan says this service is not a covered expense 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 pay for the two 
prefabricated posts and cores in addition to crowns (D2954 x2) provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness for upgrade 
to expandable controller (E2313), an electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311) and a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee presents with paraplegia, 
immobility syndrome due to paraplegia, and history of pressure sores on pelvis and buttocks. There is not a 
simpler wheelchair that would meet this enrollee's needs. The Plan denied your request. The Plan says the 
requested accessories cannot be covered. There is not a medical need to control these power options through 
the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the requested power seat 
elevation feature is statutorily non-covered as it serves no primary medical purpose. Provided records 
document that the enrollee has 3+/5 upper extremity strength and is independent with transfers with a sliding 
board thus indicating he has adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377), a harness for upgrade to expandable controller 
(E2313), an electronic connection between wheelchair controller and 2 or more power seating system motors 
(E2311) and a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing radiographic images (D0274), a panoramic 
radiographic image (D0330), and teeth cleaning (D1110) provided on May 19, 2022, by an out-of-network 
provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewing radiographic images (D0274), a panoramic radiographic image (D0330), and teeth cleaning 
(D1110) provided on May 19, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on January 7, 2022. 
 
You asked the Plan to pay for these services provided during an outpatient hospital procedure. You say that the 
provider determined that it was safe to perform this procedure in an outpatient hospital setting. The Plan denied 
your request. The Plan says these services were on the inpatient-only list, so it is not appropriate for your 
hospital to bill these as outpatient services. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 58275. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for outpatient hospital services provided on January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on May 3, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 14, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the knee x-ray rendered on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #3. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the x-rays show a 
crown already present on tooth #3 with no new decay. The Plan also says that this tooth does not meet clinical 
requirements for a crown 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 crown 
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 the crown. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for a replacement crown for tooth #3. Our 
physician reviewer found the documentation indicates that the crown presently in place on tooth #3 appears 
adequate. Our reviewer also found that no recurrent decay was noted and there was no narrative indicating the 
reason for a replacement of the crown. 
 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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on November 29, 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 as the records submitted were incomplete. Maximus overturned the Plans denial stating the services were necessary. The Plan requested a reopen and stated the issue was not medical necessity, but the incomplete data submitted with the medical records.
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. The rules also say that the medical records provided must support the services billed. The medical records provided are not properly signed and dated for the date of service listed on the claim. Therefore, we decided that the Plan does not have to pay for pain management services provided to the enrollee on November 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service February 3, 
2022. 
 
You asked the Plan to pay for procedure code 99072. The Plan denied your request. The Plan says procedure 
code 99072 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for date of service 
May 10, 2021. 
 You asked the Plan to pay for procedure code 75726 and 75774. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 75726 and 75774 is bundled into payment for code 
37243. 
 
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 codes 
75726 and 75774 are column II codes to column I code 37243. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for 
date of service May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2021 billed with 
codes 81105, 81225, 81226, 81230, 81240, 81241, 81291, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 29, 2021 billed with codes 81105, 81225, 81226, 81230, 81240, 81241, 81291, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on February 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for this 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) 
provided on February 28, 2022.