Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there has not been a qualifying face-to-face evaluation done by any of the provider. 
 
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 patients 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 the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary.  
 
 
 
 Our physician reviewer found the documentation states that you have a mobility deficit, but the documentation 
does not clearly indicate that the mobility limitation significantly impairs your ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. The documentation does not support that your mobility limitation 
cannot be sufficiently resolved by the use of an appropriately fitted manual wheelchair or walker or that your 
home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual 
wheelchair that is requested. The documentation does not support that the use of a manual wheelchair will 
significantly improve your ability to participate in MRADLs and that you will use it on a regular basis in the 
home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 11, 2021,
coded as 99231.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned
the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional coding
and claim information. The Plan demonstrated that a National Correct Coding Initiatives (NCCI) Procedure to
Procedure (PTP) edit exists between codes 99231 and 36556. This PTP edit has a modifier indicator of 1,
which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not
billed with this PTP code edit.
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, the
appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of a required
modifier. Medicare rules for coverage of this code have not been met. Therefore, we decided that the Plan does
not have to pay for physician services provided to the enrollee on July 11, 2021, coded as 99231.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on September 16, 2020, and
November 2, 2020.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says the $1500 dental benefit was exhausted prior to including some of
the services rendered on the dates in question. Maximus overturned the Plans denial for insufficient claim
information in the case file to show benefit exhaustion. The Plan requested a reopen and provided
documentation to show the $1500 benefit was exhausted.
The Plan is correct in this case. Medicare does not cover dental services. In 2020, the Plan offered a dental
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though
the Plan offered a dental benefit more than Medicare coverage, the $1500 maximum benefit had been
exhausted. Any costs over the maximum benefit are your responsibility.
Therefore, we decided that the Plan does not have to pay for dental services provided on September 16, 2020,
and November 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 3, 2021
and billed under code 93042.
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. Maximus overturned the Plans denial for a
lack of claim information in the case file. The Plan requested a reopen and provided additional claim
information. The Plan provided documentation to show a National Correct Coding Initiatives (NCCI)
Procedure to Procedure (PTP) edit exists between code 99291 and 93042. This PTP edit has a modifier
indicator of 0, which indicates there are no modifiers allowed with this PTP code pair.
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. In this case, this claim
cannot be paid as billed due to an error with the codes billed and the existing NCCI edits for these codes.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for imaging services provided to the enrollee on May 3, 2021, and billed under code 93042.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-approval for porcelain fused to high noble metal 
pontics (D6240) for tooth #'s 18 and 20 and a porcelain/ceramic pontic (D6245) for tooth #19. 
 
You asked the Plan to pre-approve the pontics. The Plan denied your request. The Plan says you have more 
than one tooth missing in the arch, which is why medical necessity is not 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 the pontics 
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 pontics. Our reviewer says that the 
pontics do not meet the criteria for coverage. Our physician reviewer found in this instance, where there is a 
missing posterior tooth, the Plan criteria for bridgework would not be met. Our reviewer found that bridgework 
under the Plan is limited to very narrow circumstances. Our physician reviewer also found that the tooth may 
be replaced by less expensive means as provided for under the Plan. 
 
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 pontics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pre-approval for porcelain fused to high noble metal pontics (D6240) for tooth #'s 18 and 
20 and a porcelain/ceramic pontic (D6245) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection (E2311). You say that the requested electronic 
connection (E2311) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic connection (E2311).  
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 an electronic connection (E2311). Our 
reviewer says that the enrollee does not meet criteria for the requested electronic connection (E2311). Our 
physician reviewer found the electronic connection (E2311) between two systems thru drive 2+ Actuators is 
not medically necessary. The requested items exceed the enrollee's medical needs. The enrollee does not 
require a ventilator, or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does 
not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee 
has power options on the wheelchair, but the enrollee does not need to control the power options through a 
joystick. The enrollee's upper extremity strength and independence in eating supports that the enrollee can 
control any power options through 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 an electronic connection (E2311) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for injections of Prolia provided to the
enrollee on November 26, 2019, and June 17, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this coinsurance is correct. The
Plan denied your request. The Plan says this coinsurance was applied based on the drug provided and the Plan
contract agreement. Maximus partially overturned the Plans denial because a 2019 contract had not been
submitted. The Plan requested a reopen and provided the 2019 contract for review.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the
Plan in 2019 and 2021 clearly says that enrollees must pay 20% coinsurance for Medicare Part B drugs. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the cost-sharing for injections of Prolia provided to the enrollee on
November 26, 2019, and June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81292, and 
81301) provided on March 7, 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 the services are not covered as billed. 
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 laboratory services have not been met. The denial remains 
upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does 
not have to pay for the laboratory services (CPT code(s): 81206, 81292, and 81301) provided on March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
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 code 76937 was previously paid and code 36000 has a status code preventing payment
on Medicare claims. Maximus partially overturned the Plans denial for insufficient proof of payment for code
76937. The Plan requested a reopen providing documentation to show code 76937 had previously been paid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Plan provided documentation to show code 76937 was previously
paid on September 21. 2021. In addition, Medicare rules state that code 36000 is always bundled for payment
and is not paid separately. Therefore, the Plan is not required to pay this claim.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT 
code 81404-XS X 2) and (CPT code 81479-XS X 1) provided on June 14, 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 the services are not supported by the records. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The services were initiated by the lab and not by the doctor. Therefore, we decided that the Plan does not have 
to pay for the cardiac risk assessment genetic screening testing (CPT code 81404-XS X 2) and (CPT code 
81479-XS X 1) provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the surgical extraction of tooth #21 
(D7210) with bone grafting (D7953) and defect repair (D7955) along with personal protective equipment 
(PPE) charges (D1999) for services provided on September 20, 2021. 
 
You asked the Plan to make additional payment for the dental services. You say that this should be covered due 
to medical necessity. The Plan denied your request. The Plan says these services are not considered medical 
and cannot be covered by Medicare. However, payment was made for the extraction based on 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 Plan's coverage rules apply in this case. 
Extraction of a tooth is considered a dental service unless it is required incidentally in order to treat a medical 
condition, e.g., removing a tooth to allow radiation treatment to an oral tumor. This tooth was removed due to 
decay, meaning it is considered dental and not covered by Medicare. 
 
The bone grafting and defect repair are not covered by the dental benefit offered by the Plan, nor is the 
upcharge for PPE. However, the dental extraction was covered per the EOC cost sharing under the dental 
benefit. The enrollee is responsible for $207 for this service: $50 deductible, plus $50 copayment, plus 50% of 
the allowed amount after the deductible ($107). Therefore, we decided that the Plan does not have to make 
additional payment for the surgical extraction of tooth #21 (D7210) with bone grafting (D7953) and defect 
repair (D7955) along with personal protective equipment (PPE) charges (D1999) for services provided on 
September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health admission and services 
provided from May 5, 2021, to May 6, 2021. 
You asked the Plan to pay for the inpatient behavioral health services from May 5, 2021, to May 6, 2021. You 
say that the services were medically necessary. The Plan denied your request. The Plan says the services were 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health services. Our 
reviewer says that the inpatient behavioral health admission was not medically necessary. Our physician 
reviewer found the records provided for the admission of this enrollee does not meet the criteria for May 5, 
2021 forward as the enrollee was not shown to be a danger to herself or others, delusions, auditory or visual 
hallucinations noted. The reviewer found that the enrollee was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
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 inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient behavioral health admission and services provided 
from May 5, 2021, to May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive to waive the coinsurance for gauze, non-impregnated, sterile
(A6219) and collagen dressing, sterile (A6021) provided on June 8, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan states this cost share was charged based on the Plan contract agreement.
Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not
apply the correct calculations. The Plan shows the Medicare Allowable Amount for code A6219 is $23.85 and
the Medicare Allowable Amount for code A6021 is $524.93. The total Medicare Allowed Amount is $548.78
and 20% of that amount is $109.75.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay 20% coinsurance for durable medical equipment.
You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive to waive the coinsurance for gauze, non-impregnated, sterile (A6219) and collagen
dressing, sterile (A6021) provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Primagen Allograft 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 the Primagen Allograft in 
the setting of anterior cervical spine fusion surgery has 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. Primagen allograft 
remains experimental for use in spinal surgery. More research is needed. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage. 
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 Primagen Allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia services (D9222 and 
D9223) provided on November 3, 2021. 
 
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that your teeth were 
infected, and you needed the sedation because of the severe pain. The Plan denied your request. The Plan says 
the documentation does not show that you were very nervous about your treatment or needed to have a lot of 
dental work done on the same day to get this drug. The Plan also says that the documentation does not show 
that your dentist also tried and failed at using a less powerful drug to help you relax. 
 
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, deep sedation/general anesthesia 
(D9222 and D9223) requires authorization. Therefore, we decided that the Plan does not have to pay for the 
deep sedation/general anesthesia services (D9222 and D9223) provided on November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on March 8,
2021, and March 9, 2021, and billed under codes 77280 and 77296.
You asked the Plan to pay for this claim. You say that this imaging should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that based on the Medicare billing guidelines, the denied codes
are included in the APC payment for code 77301 (IMRT planning).
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. Medicare does not allow
the billing of codes 77280 and 77296 in addition to the billing of code 77301. Medicare billing criteria were not
met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on
March 8, 2021, and March 9, 2021, and billed under codes 77280 and 77296.