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

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #6. 
 
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says the tooth does not appear to have significant breakdown due to decay or trauma. 
 
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 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 does not meet the criteria for coverage for a crown restoration (D2751) for tooth #6. Our 
physician reviewer found tooth #6 does not have significant coronal breakdown due to caries or fracture. Our 
reviewer also found that a root canal has been completed, and the coronal access appears to be small and not 
compromising the integrity of the coronal structure. 
 
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 (D2751) for tooth #6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator.  
You asked the Plan to pre-approve the spinal cord stimulator. You say that you would like reconsideration 
because the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for coverage. 
 
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 the spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not have psychological clearance or an evidence based indication. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided by a participating 
provider on November 30, 2021. 
 
You asked the Plan to pay for panoramic imaging. You say that you were unaware that your dentist never sent 
your new dentist your x-rays. The Plan denied your request. The Plan says the benefit limit for D0330 has 
already 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 panoramic 
imaging when the services once per a 24-month period.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0330 was provided on 
November 30, 2021. Based on this information, we decided that the Plan's rules for coverage of panoramic 
imaging have already been met. Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided by a participating provider on November 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve prostate cancer genetic testing services. 
 
You asked the Plan to pre-approve the prostate cancer genetic testing services. You say that you would like 
reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that 
you do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prostate cancer genetic testing 
services. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found you meet all of the coverage criteria as listed in the LCD. 
Specifically, you are over 50 with a confirmed moderately elevated PSA, no other relative indication for 
prostate biopsy and no other relative contraindication for prostate biopsy. 
 
 
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 prostate cancer genetic testing services have been met. Therefore, we 
decided that the Plan has to pre-approve prostate cancer genetic testing services.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for SNF care.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF care was
medically necessary. The Plan denied your request. The Plan says Medicare criteria were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The
Maximus Physician Reviewer determined that you required intravenous Rocephin daily. The Plan requested a
reopen and argues that once daily antibiotic administration is routinely provided in settings other than inpatient
care, such as in the home with home health care, in residential care, or home with close follow-up with the
doctor. The Plan is correct in this case. An IV antibiotic may be administered at a lower level of care. In
addition, the documentation supports that the course of IV antibiotic in this case would have been completed
and was no longer an issue. Medicare criteria for SNF care were not met.
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 provide coverage for SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liver hemorrhage treatment provided during a surgical 
procedure on June 26, 2021, billed with code 47361. 
 
You asked the Plan to pay for the services as billed. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the reported code 47361 is not supported by the surgical 
records. 
 
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 47361 is management of liver hemorrhage; exploration of 
hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver. 
 
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 the services as billed. Our reviewer says that the billed code 
is not supported in the record. Our reviewer found the operative report describes a liver tear due to dissection 
required to expose hepatic artery for retrograde bypass. To cite the operative report: "Following successful 
bypass, the operation was then turned back over to general surgery, and there had been the liver tear innate to 
the dissection that was required in order to expose the hepatic artery for retrograde bypass. Had some extensive 
bleeding. Hemostasis was done thank FloSeal with QUICK clot gauze packed with a lap pad packed 
underneath the liver intentionally until returned to the operating room".   
 
In this case, the operative report describes a liver tear due to dissection required to expose hepatic artery for 
retrograde bypass, which would not be covered separately from the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the liver hemorrhage treatment provided during a surgical procedure on June 26, 2021, 
billed with code 47361.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and custom sleep 
apnea appliance (D9947) provided on October 13, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and custom sleep apnea appliance. You say 
that you do not have any other health insurance, and fully expected a reimbursement of at least $107 for these 
services. The Plan denied your request. The Plan says these procedures are not covered 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 Plan's 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 first 
intraoral periapical x-ray (D0220) and custom sleep apnea appliance (D9947) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) teeth extractions (D7210) and treatment of a root 
canal obstruction (D3331) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve teeth extractions and treatment of a root canal. You say that you are in 
excruciating pain that never stops. You also say that you have never used your plan benefits and you think that 
the Plan should cover at least one extraction. The Plan denied your request. The Plan says the plan only 
provides coverage for dental services when they are performed by a participating general dentist. The Plan also 
says dental services performed by an oral surgeon are not covered. 
 
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 teeth 
extractions and treatment of a root canal when the services are performed by a participating dentist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of teeth extractions and treatment of a root canal have not been met. Specifically, dental services must 
be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve six (6) teeth extractions (D7210) and treatment of a root canal obstruction (D3331) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RhinAer radiofrequency ablation (RFA) device. 
 
You asked the Plan to pre-approve the RhinAer RFA device. You say that you would like reconsideration 
because the requested procedure is medically necessary. The Plan denied your request. The Plan says this does 
not meet Medicare criteria for coverage. 
 
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 the RhinAer RFA device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a meta-analysis of randomized controlled trials comparing microdebrider-assisted 
turbinate reduction and RFA of the inferior turbinates demonstrated better objective and subjective clinical 
outcomes among patients who underwent microdebrider-assisted turbinate reduction, particularly at long-term 
follow-up (1-2 years postoperatively). Overall, there is insufficient high-quality, peer-reviewed evidence to 
support the use of intranasal RFA over other available therapies. 
 
 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 RhinAer RFA device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the RhinAer radiofrequency ablation (RFA) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970) provided 
August 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
 
 
 
 
 We looked at the file and Medicare rules. These services are related to ESRD treatment and are not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 
83550, 83970) provided August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the scanning computerized ophthalmic 
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), 
intravitreal injection of a pharmacologic agent (67028), and compounded drug, not otherwise classified (J7999) 
provided December 6, 2021. 
 
You asked the Plan to waive the cost-sharing for the scanning computerized ophthalmic diagnostic imaging, 
injection of eye drug and compounded drug. You say that you were under the impression you would only have 
a $20 copayment. The Plan denied your request. The Plan says the cost-sharing was applied correctly. 
 
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 Medicare Part B prescription drugs and a $20 copayment per visit to an ophthalmologist or 
optometrist for Medicare-covered vision care. 
 
You have been asked to pay a $20 copayment for the eye scan and injection and a total of $14.08 ($70.41 
allowed amount x 20% coinsurance = $14.08) for the compounded drug. This means that 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 
the cost-sharing for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report, unilateral or bilateral; retina (92134), intravitreal injection of a pharmacologic agent 
(67028), and compounded drug, not otherwise classified (J7999) provided December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidurography services provided on July 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 72275 is epidurography, radiological supervision and 
interpretation. The records show that an epidurography was provided in conjunction with transforaminal steroid 
injections. The medical records provided do not show that the service billed with the -59 modifier is a distinct 
procedural service.  Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the epidurography services 
provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for a lower intestinal endoscopic procedure 
(00811) provided on September 11, 2020. 
 
You asked the Plan to pay for anesthesia for a lower intestinal endoscopic procedure. You say that the service 
was billed with the appropriate QX modifier as it was performed by a nurse anesthetist in conjunction with an 
anesthesiologist. The Plan denied your request. The Plan says the diagnosis on the claim did not support the 
level of anesthesia care. 
 
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 pay for anesthesia for a lower intestinal endoscopic 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation in the enrollee's record 
indicating that it is medically necessary to have an anesthesiologist present during the colonoscopy.  The 
review has determined that this patient does not have a diagnosis, condition, and/or symptoms that meet the 
Medicare 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 anesthesia for a lower intestinal endoscopic procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia for a lower intestinal endoscopic 
procedure (00811) provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy.
You asked the Plan to pre-approve this treatment. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy. The Maximus Physician Reviewer determined that bioimpedance spectroscopy for breast cancer
related lymphedema assessment was necessary. The Plan requested a reopen and argues that the medical
records show your lymphedema is controlled with use of a compression sleeve and the need to continue to
monitor for subclinical lymphedema is not reasonable or medically necessary. The Plan is correct in this case.
The medical records submitted indicate you reported the left upper extremity lymphedema is controlled, and
you continue to wear the compression sleeve. There is no mammographic or MRI evidence of malignancy. The
available documentation does not support that bioimpedance spectroscopy is medically 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 this treatment have not been met. Therefore, we decided that the Plan does not
have to pre-approve bioimpedance spectroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
November 5, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you believe this x-ray should 
be covered under bitewings. 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 Plan's 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. The only type of x-rays that are covered under your plan are bitewing 
x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays 
(D0210) provided on November 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergency ambulance 
transportation (A0428) provided on September 8, 2021. 
 
You asked the Plan to waive the copayment for the non-emergency ambulance transportation. You say that the 
hospital ordered an ambulance for and transported you against your will. You also say that you feel neither you 
nor your insurance should have to pay any charges to for the ambulance. The Plan denied your request. The 
Plan says the copayment amount you are being charged is correct. 
 
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 a $150 
copayment for each Medicare-covered ground ambulance service for Ambulance Services.  
 
 You have been asked to pay a $150 copayment for each Medicare-covered ground ambulance service for the 
non-emergency ambulance transportation. The non-emergency ambulance transportation falls within the 
Ambulance Services benefit category. This means that 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 the copayment for the non-emergency 
ambulance transportation (A0428) provided on September 8, 2021.