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

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on August 24, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not aware that you needed a prior 
authorization, you should not be responsible for the charges. The Plan denied your request. The Plan says this 
service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0350 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology procedure services provided on 
September 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology procedure. You say that you work with a number of doctor 
groups who are participating provider. The Plan denied your request. The Plan says services can be obtained 
from an in-network provider and there is no prior authorization on file for the services obtained. 
 
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 surgical pathology procedure services provided on 
September 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on July 08, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you want to see this provider, their services help 
your health issues. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on July 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyOwn skin (Q4226) and the application of skin substitute graft (15271) for the enrollee.
You asked the Plan to pre-approve these services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are not a covered benefit.
Our Medical director looked at the case file and the reopen request. At issue is coverage for MyOwn skin and the application of skin substitute graft. Our Medical Director states that MyOwn skin was not FDA-approved or FDA-cleared. There is insufficient support to demonstrate that MyOwn Skin was medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that your 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 MyOwn skin (Q4226) and the application of skin substitute graft (15271) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) provided 
from March 1, 2022, through June 16, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) provided from  
March 1, 2022, through June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4208 and A4216 billed for dates of service 
July 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges were appropriate for the level of 
services. The Plan denied your request. The Plan says the codes are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that there is no separate payment for CPT codes A4208 and A4216. Payment is packaged into payment 
for other services. 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 pay for procedure codes A4208 and A4216 billed for 
dates of service July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 1,
2022.
You asked the Plan to pay for the dental services. You say that you were referred to this dentist for services,
and the dentist should be paid. 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 Plan's 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 August 4, 2022.
Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on
September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80048 billed for date of service July 6, 2021. 
 You asked the Plan to pay for procedure code 80048. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 80048 is bundled into payment for code 80053. 
 
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 80048 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code is therefore not 
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 code 80048 billed for date of service July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOneCDx (F1CDx) testing provided to the enrollee on August 26, 2021.
You asked the Plan to pay for the testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOneCDx (F1CDx) testing provided to the enrollee on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 crowns (D2740), 2 core buildups (D2950), guided 
tissue regeneration (D4266), a pontic (D6245), 2 retainer crowns (D6740), and a bone replacement graft 
(D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your benefit for the crowns, core buildups, pontics, and 
retainer crowns has already been exhausted. The denial of authorization for the guided tissue regeneration and 
bone replacement grafts is correct, because they are not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that the Plan has pre-approved 3 crowns (D2740) and 3 core buildups (D2950). This will exhaust your 
benefits for the crowns, core buildups, pontics, and retainer crowns. The guided tissue regeneration and bone 
replacement grafts are not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not 
have to pre-approve 2 crowns (D2740), 2 core buildups (D2950), guided tissue regeneration (D4266), a pontic 
(D6245), 2 retainer crowns (D6740), and a bone replacement graft (D7953).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FANCC genetic testing provided to the enrollee on February 2, 2022.
You asked the Plan to pay for the genetic testing. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that the specimen was collected in the hospital.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was collected in the hospital. 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 code. In this case, this claim cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided to the enrollee on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (D9440) provided on September 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that the office visit should be covered under an 
emergency situation. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the office visit and the dental code of D9440 is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an office 
visit (D9440) provided on September 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient services for shoulder surgery. 
 
You asked the Plan to pre-approve inpatient services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 inpatient services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a diagnosis of primary osteoarthritis, left shoulder. You are undergoing a 
planned left reverse total shoulder arthroplasty. You are medically stable and has been provided medical 
clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. 
There is no documentation provided to support the expectation you will require inpatient admission.  Therefore, you do not meet criteria for the requested inpatient 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 inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient services for shoulder surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this dentist for services, 
and the dentist should be paid. 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 [Enter date the requested 
item or service was exhausted]. Therefore, we decided that the Plan does not have to pay for the limited oral 
exam (D0140) provided on September 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care associated with a bronchoscopy 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs treatment. The 
Plan denied your request. The Plan says that the notes we received do not show that the enrollee's care qualifies 
for an inpatient stay at this time. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the 3-midnight hospital stay is reasonable and medically necessary. This enrollee 
has severe chronic obstructive pulmonary disease (COPD) with hyperinflation and has been approved for 
bronchoscopic placement of Zephyr endobronchial valves to achieve lung reduction. A frequent complication 
of this procedure is pneumothorax, caused by rapid expansion of untreated lung regions. Pneumothorax can be 
life threatening in patients with severe lung disease and may require immediate treatment to preserve life. FDA 
approval of the Zephyr system includes a 3-day hospital stay after the procedure. It is not safe to discharge the 
enrollee following the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care associated with a bronchoscopy  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 29881 and 29876 for date of service January 19, 2022.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus partially overturned the Plans denial stating code 29881 should be paid and code 29876 was denied appropriately. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan sent documentation to show payment for code 29881 is included in the payment of 29879 and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the Plan has demonstrated that code 29881 was denied by the Plan appropriately due to the bundled relationship with other codes on the claim. Both the Plan and Maximus previously agreed code 29876 should be denied because the operative report does not support synovectomy was performed other than for joint clean up. Synovectomy would be covered separately from the more extensive procedure, when there is a pathologic synovial disease, and not for joint clean up. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee and billed under codes 29881 and 29876 for date of service January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation system. You say that you are appealing this denial. The 
Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton treatment delivery (77523) for the enrollee.
You asked the Plan to pre-approve proton treatment delivery. You say that proton therapy has been proven safe and effective for prostate cancer and these services are necessary. The Plan denied your request. The Plan says that these services are not medically necessary as they are not indicated for the treatment of prostate cancer.
Our Medical director looked at the case file and the reopen request. At issue is coverage for proton treatment delivery. Our Medical Director states that NCCN Guidelines Version 1.2023 Prostate Cancer states, "The NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to x-ray-based regimens at clinics with appropriate technology, physics, and clinical expertise." The Guidelines further state, "The American Society for Radiation Oncology (ASTRO) evaluated proton therapy and created a model policy to support the society's position on payment coverage for proton beam therapy in 2014. This model policy was updated in 2017 and recommends coverage of proton therapy for the treatment of non-metastatic prostate cancer if the patient is enrolled in either an institutional review board (IRB)-approved study or a multi-institutional registry that adheres to Medicare requirements for Coverage with Evidence Development (CED)." The documentation does not support that the enrollee in this case is enrolled in such a study or registry. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of proton treatment delivery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the Plan does not have to pre-approve proton treatment delivery (77523) for the enrollee.