Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records 
provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical 
conditions are stable on outpatient medications with no issues that require a physicians evaluation three or 
more times per week. The enrollee does require physical therapy and occupational therapy services, but the 
medical records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy 
program. Provided records do not explain why the intensive inpatient rehabilitation therapy program is 
necessary and why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided on 
July 9, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
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 genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206 and 81292) provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (disposable wipes or cleansing 
wipes). 
 
You asked the Plan to pre-approve incontinence supplies (disposable wipes or cleansing wipes). The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (disposable 
wipes or cleansing wipes).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6240) and comprehensive oral evaluation 
(D0150) provided on February 14, 2022. 
 
You asked the Plan to pay for the pontic and comprehensive oral evaluation. You say that the crown was billed 
incorrectly by the dental office. You also say that you would like a partial payment for the large expenditure. 
The Plan denied your request. The Plan says pontic is not a covered expense under your dental plan. The Plan 
also says that your benefits for the comprehensive oral evaluation have been satisfied and the frequency 
limitation has 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, pontic (D6240) is not among those 
covered under this benefit. The contract says that 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 August 28, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the pontic (D6240) and comprehensive oral 
evaluation (D0150) provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for therapeutic apheresis for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment is medically necessary
for the enrollee. 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
coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for therapeutic
apheresis. The Maximus Physician Reviewer determined that, although the enrollee did not have a covered
indication per the National Coverage Determinations Manual, Familial hypercholesterolemia is an indication
for this procedure when other standard treatment options are exhausted based on current supportive evidence.
The Plan requested a reopen and stated that NCD 110.14 does not list hyperlipidemia or hypercholesterolemia
as a covered diagnosis.
Our Medical Director has concluded that the Plan is correct in this case. There are no studies that have
demonstrated improved survival with therapeutic apheresis for patients with hyperlipidemia. In addition, there
are known side effects and potential downside risk of the treatment regimen. It would not be appropriate to
assume benefit of the procedure 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 therapeutic apheresis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81321, 81206, and 81235) 
provided on August 6, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
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 genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81321, 81206, and 81235) provided on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 tests purchased January 20, 2022. 
 
You asked the Plan to pay for the home tests. You say that you were unaware of the date that COVID tests 
were being covered. You would like the reimbursement to be considered. The Plan denied your request. The 
Plan says the at home COVID-19 test was purchased prior to the Plan's effective date of 02/01/2022. 
 
The Plan must follow Medicare rules. The Plan offers a benefit that exceeds Medicare coverage. In this case, 
the Plans rules apply. The health Plan contract shows that the Plans effective date of coverage for the 
purchase of at home COVID-19 tests is February 1, 2022. Therefore, we decided that the Plan does not have to 
pay for the at home COVID-19 tests purchased January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on April 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider participated with 
your insurance. 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 a panoramic x-ray (D0330) provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided October 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the testing performed is not covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. This test is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81455) provided October 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Revo Fit socket. 
 
You asked the Plan to pre-approve a Revo Fit socket. You say that the requested Revo Fit socket is medically 
necessary. The Plan denied your request. The Plan says the requested Revo Fit socket is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Revo Fit socket. Our reviewer says 
that the requested Revo Fit socket is not medically necessary. Our physician reviewer found the enrollee has 
requested a REVO fit prosthesis as he feels the adjustable pressure will be useful for his varied walking tasks. 
His residual limb has shrunk since the prosthesis was originally fitted. Revo fit does not have FDA approval 
per their website.  The socket addition is billed under L5999. Per Medicare policy, code L5999 may not be used to bill for 
additions to a socket. Per Medicare rules the requested device is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Revo Fit socket have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Revo Fit socket.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular denture (D5140) and 
extraction of tooth #22 (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for an extraction of tooth #22 has already 
been exhausted. An immediate mandibular denture (D5140) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 20, 2022. An 
immediate mandibular denture (D5140) is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve an immediate mandibular denture (D5140) and extraction of tooth #22 (D7140).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral open sacroiliac (SI) joint fusion (27280) 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 bilateral open SI joint 
fusion procedure in the setting of clinical documentation that does not demonstrate any evidence of sacroiliac 
joint instability, fracture, or tumor presence 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. There is no SI joint 
instability, fracture or lesion. SI joint fusion remains experimental at this time. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 bilateral open sacroiliac (SI) joint fusion (27280) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable concentrator is 
medically necessary. The Plan denied your request. The Plan says the enrollee has already been issued oxygen 
equipment that meets their needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable oxygen tanks. The portable oxygen tanks serve the same purpose as a 
portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair coded K0823 provided on November 1, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item billed is not a covered benefit. 
 
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 K0823 is power wheelchair, group 2 standard, captains 
chair, patient weight capacity up to and including 300 pounds. 
 
We find that CPT code K0823 is not supported in the medical record. Specifically, this code is only covered 
once every 28 days. This code was previously billed on October 10, 2021. This was billed within 27 days of the 
previous date of service. This means this is not a covered benefit since it is only covered once every 28 days. 
Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been 
met. Therefore, we decided that the Plan does not have to pay for the power wheelchair coded K0823 provided 
on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $40 copayment charged for a pulmonologist
specialist office visit provided on December 6, 2021.
You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is
correct. The Plan denied your request. The Plan says the medical records show you had a specialist office visit
which requires a $40 copayment. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct contract language.
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 a $40 copayment for specialist service.
The records show you had a visit with a nurse practitioner at a pulmonologist office. A pulmonologist is a
specialist. 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 or reduce the $40 copayment charged for a pulmonologist specialist office visit
provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are allowed two cleanings per year, and you 
had only had one so far this year. 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 January 13, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for endodontic therapy on tooth #10 (D3310) provided on March 7, 2022. 
 
You asked the Plan to pay for endodontic therapy. The Plan denied your request. The Plan says that your yearly 
maximum benefit has been exhausted. 
 
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 did not provide documentation showing that your annual benefit 
maximum for dental services has been met. Without that documentation we are unable to determine if you are 
responsible for the balance. Therefore, we decided that the Plan has to pay for endodontic therapy on tooth #10 
(D3310) provided on March 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the testing performed is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
gene are statutorily non-covered. 
 
We looked at the file and Medicare rules. The panel included the FANCC gene and is non-covered. 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 (0037U) provided January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 12,
2021, 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. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
demonstrated that per National Correct Coding Initiative (NCCI) Guidelines, procedure code 93042 has an
unbundled relationship with procedure code 99291 submitted on the same claim. The PTP Edit has a Modifier
Indicator of "0", the result is code 93042 remains ineligible for payment. A medical necessity review was not
completed as the denial was not for medical necessity. The PTP edit table contains edits which are pairs of
HCPCS/CPT codes that in general should not be reported together. Per National Correct Coding Initiative
(NCCI) Guidelines, procedure code 93042 has an unbundled relationship with procedure code 99291. Each edit
has a Column One and Column Two HCPCS/CPT code. If a provider reports the 2 codes of an edit pair, the
Column Two code is denied and the Column One code is eligible for payment. Each NCCI PTP edit has an
assigned modifier indicator. The PTP edit for procedure codes 99291 and 93042 has a modifier indicator of
"0", which indicates there are no modifiers that are allowed with this PTP pair. There are no circumstances in
which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the
same provider.
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, code 93042 cannot be paid as billed due to its unbundled relationship to code 99291. These codes
were billed inappropriately based on the Medicare billing guidelines. Therefore, we decided that the Plan does
not have to pay for physician services provided to the enrollee on August 12, 2021, under code 93042.