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

We decided that the Plan does not have to pre-approve thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision (CPT code 35301) and anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries (CPT code 61711).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this type of procedure has not been demonstrated to be any more effective than not having surgery to reduce the risk of having a stroke.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is excluded by rule for the noted indication. The elements of the coverage criteria are not satisfied. The requested service is not recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision (CPT code 35301) and anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries (CPT code 61711).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #18 (D2950) and a crown on tooth 
#18 (D2740) provided on January 6, 2022. 
 
You asked the Plan to pay for core build up and a crown. You say that you were advised these services were 
covered. The Plan denied your request. The Plan says core build up (D2950) and a crown (D2740) are 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 pay for core build 
up on tooth #18 (D2950) and a crown on tooth #18 (D2740) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service February 17, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that this service should be covered. The Plan 
denied your request. The Plan says payment for code G0453 is bundled into payment for code 95940.  
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 code G0453 
is a column II code to column I code 95940. 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 code G0453 billed for date of service February 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, above knee or knee 
disarticulation, acrylic socket (L5631), a custom shaped protective cover, above knee (L5705), and an addition, 
endoskeletal system, high activity knee control frame (L5930). 
 
You asked the Plan to pre-approve lower extremity prosthetics. You say that you disagree with the denial of 
prosthetics. The Plan denied your request. The Plan says the acrylic socket and the custom shaped protective 
cover is not covered and denied as not reasonable and necessary. The Plan also says the high activity knee 
control frame is covered for beneficiaries whose functional level is 4. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that the acrylic socket and the custom shaped 
protective are not deemed reasonable and necessary. Medicare rules also say that the high activity knee control 
frame is covered for beneficiaries who functional level is 4. The records show that your functional level is K3. 
Based on this information, we decided that Medicare rules for coverage of lower extremity prosthetics have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an addition to lower extremity, 
above knee or knee disarticulation, acrylic socket (L5631), a custom shaped protective cover, above knee 
(L5705), and an addition, endoskeletal system, high activity knee control frame (L5930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447 and 99100 billed for date of service 
March 7, 2022. 
 
You asked the Plan to pay for procedure codes 64447 and 99100. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 
01402 and 64447. 
 
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 code 64447 
is a column II code to column I code 01402. This claim has not been billed with an appropriate modifier to 
bypass the edit. We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99100 is not separately payable. 
 
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 64447 and 99100 billed for date of service March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 the dental services on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted navigation. 
 
You asked the Plan to pre-approve computer-assisted navigation. You say that the records provided support the 
need for computer-assisted navigation. The Plan denied your request. The Plan says the current evidence-based 
medical literature does not support the routine use of computer-assisted navigated total joint arthroplasty over 
conventional total joint arthroplasty. 
 
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 computer-assisted navigation. Our 
reviewer says that computer-assisted navigation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no large volume, long-term/high-quality clinical studies that 
confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted navigation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computer-assisted navigation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair resin denture base (D2391) and the resin-based 
composites (D2391x2) provided on June 14, 2022. 
 You asked the Plan to pay for the repair resin denture base (D5610) and the resin-based composite (D2391x2). 
You say that the services should be covered. The Plan denied your request. The Plan says D5610 is not a 
covered benefit and D2391x2 was paid on the least costly method of treatment. 
 
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 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 50% coinsurance for the fillings 
and the difference between the allowed amounts of the billed code and the least costly code. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the repair resin denture base (D2391) 
is not among those covered under this benefit. You have been asked to pay $72.50 per filling. The allowed 
amount of D2391 was $116 and the allowed amount of the alternate code D2140 was $87. ($87.50 x 50% = 
$43.50). The difference between the allowed amounts of D2391 and D2140 is $29. ($116 - $87 = $29). (43.50 
+ 29 = $72.50 per filling). Therefore, we decided that the Plan does not have to pay for the repair resin denture 
base (D2391) and the resin-based composites (D2391x2) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bitewing radiographic image (D0270) provided on June 17, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the benefit limitations. 
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 April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for a bitewing radiographic image (D0270) provided 
on June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that elevating leg rests were requested. The records do 
not show that the enrollee has significant edema of the lower extremities. A seat belt was also requested. This 
item is included in the basic equipment package. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve power 
wheelchair options.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0150), radiographic images 
(D0210), and fillings (D2330 and D2391) for tooth #5, #11, #12, #20, #21, and #22 provided on February 16, 
2022, and February 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought the provider was an in-
network provider and you would like the dental procedures to be covered. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The Plan also says your benefit for the fillings 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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record also shows your benefit for the fillings was exhausted on date of service of February 25, 2022. 
Therefore, we decided that the Plan does not have to pay more for an oral evaluation (D0150), radiographic 
images (D0210), and fillings (D2330 and D2391) for tooth #5, #11, #12, #20, #21, and #22 provided on 
February 16, 2022, and February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement, subcutaneous tissue (11042) provided on June 
16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that emergency wound care was provided as 
medically necessary in the absence of a contracted/available wound care professional. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for debridement, subcutaneous tissue (11042) 
provided on June 16, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing (87481, 
87500, 87511, 87640, 87653, 87798 and 87801) provided on July 8, 2021. 
 
You asked the Plan to pay for urine PCR testing. You say that this testing was medically necessary and should 
be paid. The Plan denied your request. The Plan says the enrollee does not meet the criteria for necessity of this 
test. 
 
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 urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records submitted contained a copy of the PCR results only. No other clinical 
records were submitted that detailed the presence of a UTI, the completion of a standard culture and sensitivity, evidence of an immunocompromised state, a history of antibiotic resistance in treating the urinary tract 
infection and/or an office note from the referring provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing (87481, 87500, 87511, 87640, 87653, 87798 
and 87801) provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polishing/resurfacing of ocular prosthesis (V2624) provided 
June 6, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you are a very rare sub-specialty and there 
is no in-network provider to perform these services. The Plan denied your request. The Plan says the provider 
is a non-participating and the provider's taxonomy code is not eligible for enrollment with Medicare. This 
provider was not certified/eligible to be paid for this procedure/service on this date of service. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for polishing/resurfacing of ocular 
prosthesis (V2624) provided June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the acute inpatient hospital care 
provided from March 22, 2022, to June 5, 2022. 
 
You asked the Plan to waive the cost sharing amounts for the inpatient care. You say that you should not be 
responsible for the cost sharing amounts. You also say that you were treated poorly and neglected during your 
time in the hospital. The Plan denied your request. The Plan says this cost sharing was charged 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 $335 
copayment per day for the first 6 days for Inpatient hospital care.  
 
You have been asked to pay $335 copayment per day for the first 6 days for the inpatient care. This service falls within the Inpatient hospital care 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. The record shows that you had 3 separate inpatient hospital admissions. The 
record shows that the first admission was 1 day, with a copayment of $335. The record shows that the second 
admission was 4 days, with a copayment of $1,340 ($335 x 4). The record shows that the third admission was 
more than 6 days, with a copayment of $2,010 ($335 x 6). $335 + $1,340 + $2,010 = $3,685. Therefore, we 
decided that the Plan does not have to waive the cost sharing amounts for the acute inpatient hospital care 
provided from March 22, 2022, to June 5, 2022.  
 
Maximus read your letter and knows that you may have a quality-of-care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for the telehealth visit (99202) provided on February 
9, 2022. 
 
You asked the Plan to pay an additional amount for the telehealth visit. You say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says that the claim processed correctly. 
 
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. Specifically, the file does not support that the enrollee's deductible had not been 
met at the time the claim was processed. Therefore, we decided that the Plan has to pay an additional amount 
for the telehealth visit (99202) provided on February 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the External electrocardiographic recording (93225) 
provided on March 1, 2022. 
 You asked the Plan to pay for procedure code 93225. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the External 
electrocardiographic recording (93225) provided on March 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on April 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergent ambulance services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided on 
April 21, 2022, by an out-of-network (OON) provider.