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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 6, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 6, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from June 6, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of June 6, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond June 6, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
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 psychiatric care from June 6, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 6, 2022, 
forward.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the revascularization for right and left femoral, popliteal, 
tibial/peroneal arteries (CPT code(s): 37224, 37225, 37226, 37227, 37228, and 37229). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee's records do not show occlusive artery disease (blockage) imaging 
studies confirm the site of the blockage to be more than 50 percent (%). 
 
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 physician reviewer 
found the documentation supports the medical necessity of the treatments in question. The enrollee has 
nonhealing wounds of the lower extremities. The abnormal femoral pulses in combination with monophasic 
waveforms without stenosis of the lower extremities are all consistent with aortoiliac arterial occlusive disease. 
Angiography and possible angioplasty and stenting would be the appropriate treatments for this condition. If 
the enrollee does have nonhealing ulcers based on ischemia, nonintervention could be limb threatening. As a 
result, Iliac artery PTA and stenting has been approved by the health plan. It is possible that at the time of 
angiography, additional lesions in the lower extremities may be identified that did not show on the duplex 
examination as the velocities may be masked by the more proximal iliac artery disease. These angiographic 
codes are just preliminary as it is impossible to know exactly which vessels will be treated until the angiogram 
is performed.  Ultimate coverage will require demonstration of significant disease on the angiogram. 
Recommend approval of codes in question as criteria are 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve the revascularization for right and left femoral, popliteal, tibial/peroneal arteries (CPT code(s): 37224, 
37225, 37226, 37227, 37228, and 37229).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that transurethral 
waterjet ablation of the prostate is medically necessary. The Plan denied your request. The Plan says that 
transurethral waterjet ablation of the prostate is not medically necessary. 
 
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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the requested transurethral waterjet ablation of the prostate is considered 
medically reasonable and necessary in this case. Our physician reviewer found that the records show that the 
enrollee has failed medical therapy for more than 3 months and has clinical evidence of significant bladder 
outlet obstruction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have been met. Therefore, we 
decided that the Plan has to pre-approve transurethral waterjet ablation of the prostate.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and two prophylaxes (D1110 x2) provided on February 9, 2021, and August 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxes. You say that you 
did not know that the treating provider was not in-network. The Plan denied your request. The Plan says 
services performed by an OON provider are not covered because your healthcare plan does not have OON 
benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and two prophylaxes (D1110 x2) provided 
on February 9, 2021, and August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D4910) provided on September 28, 2021.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says the $500 maximum benefit was exhausted during this
appointment. Maximus overturned the Plans denial stating the type of service provided is covered by the Plan.
The Plan requested a reopen and stated that the issue was not the service provided but the fact that prior to the
appointment, only $68 was available out of the $500 benefit and that was exceeded during the appointment.
The Plan is correct in this case. 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 provided documentation to show the year began with a $500 maximum benefit. After the dental
services provided on January 19, 2021, $303 remained from the $500 benefit. After the dental services
provided on April 8, 2021, $280 remained from the $500 benefit. After the dental services provided on May 11,
2021, $68 remained from the $500 benefit. The dental services provided on September 28, 2021, totaled $320
which absorbed the $68 remining of the $500 benefit. Any balance after the benefit exhausted is your financial
liability per the Plan contract agreement.
Therefore, we decided that the Plan does not have to pay for dental services (D4910) provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81479 provided on November 
14, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation shows that code 81479 was submitted on its own separate claim form 
whereas the other codes were submitted on a different claim form, but testing was performed at the same time 
on the same specimen. When a laboratory assays two or more genes in an enrollee in parallel, those two or 
more genes will be considered part of the same panel. 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 laboratory testing coded 81479 provided on November 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(CPT code 64484). 
 
You asked the Plan to pre-approve the service. You say that this is an effort to improve the enrollee's function 
and quality of life. The Plan denied your request. The Plan says the enrollee's request is not medically 
necessary because their records do not show documentation of at least 50% sustained improvement in pain for 
at least three (3) months duration as a second block. The Plan states the enrollee's records indicate that the 
enrollee had only minimal pain improvement at L5 and S1. 
 
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 service. Our physician reviewer 
found selective nerve root blocks are designed to clarify the patient's pathology. They are NOT intended for 
ongoing therapeutic administration of steroids. A second selective nerve root block (SNRB) is not indicated 
here, and the request is not medically reasonable or 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 the service have 
not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) 
and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each 
additional level (CPT code 64484).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on August 30, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this is medically necessary testing that 
should be paid. The Plan denied your request. The Plan says this was not billed with a single code. Therefore, 
only 4 of the 14 billed line items are approved for payment. 
 The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. This is an NGS panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the Tempus gene panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel 
provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all four mouth 
quadrants. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve 
gingival irrigation (D4921) for all four mouth quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a simple extraction (D7140) and bone replacement graft 
for ridge preservation (D7953) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the simple extraction and bone replacement graft. The Plan denied your 
request. The Plan says these procedures are not covered benefits when rendered by a dentist who does not 
participate in the Plan's program. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
simple extraction (D7140) and bone replacement graft for ridge preservation (D7953) to be rendered by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - four or more surfaces for tooth #3 
(D2394) provided by a participating provider on October 30, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you needed the dental services provided. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 a resin-
based composite - four or more surfaces for tooth #3 (D2394) provided by a participating provider on October 
30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260), bone replacement graft 
(D4263), and guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve an osseous surgery, bone replacement graft, and guided tissue regeneration. 
You say that the enrollee is sick, and this treatment is medically necessary because of the infection. The Plan 
denied your request. The Plan says these services are not covered under the enrollee's benefit package. 
 
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 pre-approve an 
osseous surgery (D4260), bone replacement graft (D4263), and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the soft tissue allograft procedure (code D4275) you received 
from your dentist on December 6, 2021. 
 
You asked the Plan to pay for the soft tissue allograft procedure (code D4275). You say that your dentist 
advised that this service was medically necessary in order to keep your filling from falling out. The Plan denied 
your request. The Plan says this service is not covered under 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. Your dental benefit includes 
coverage only for those dental services listed in your Dental Benefits Chart. The soft tissue allograft procedure 
(code D4275) you had is not listed as a covered service.  This means it is never covered, regardless of the 
appropriateness of the service. 
 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 soft 
tissue allograft procedure (code D4275) you received from your dentist on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of lateral exostosis (D7471), removal of torus 
mandibularis (D7473), and deep sedation/general anesthesia (D9222) provided on July 29, 2021. 
 
You asked the Plan to pay for the removal of lateral exostosis, removal of torus mandibularis, and deep 
sedation/general anesthesia. You say that you made a payment of approximately $3,000 for these dental 
services because the Plan did not cover them. The Plan denied your request. The Plan says these services 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 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. The only type of sedation that is covered under your plan is conscious 
intravenous sedation. Therefore, we decided that the Plan does not have to pay for the removal of lateral 
exostosis (D7471), removal of torus mandibularis (D7473), and deep sedation/general anesthesia (D9222) 
provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim complete upper denture (D5810) provided on 
January 27, 2022. 
 
You asked the Plan to pay for the dental item. You say that you were advised you could be seen at this facility. 
You say that you would not have gone to this office otherwise. You also say that The Plan denied your request. 
The Plan says dentures are not covered. The Plan also says that you signed a treatment plan prior to the date of 
service acknowledging that you would be financially responsible for the out of pocket expense for the 
interim complete dentures. 
 
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 interim complete upper denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim complete upper denture (D5810) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. You say that you started this 
dental process last year when it was covered under your plan, but now this year it is no longer covered. You 
also say that these services are very important because you need to eat and continue with the dental process. 
The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve 
abutment supported cast metal crowns (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extraction of tooth #29 (CPT code D7140) to 
be provided by an out-of-network oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your tooth is cracking to the root and 
causing a lot of pain. The Plan denied your request. The Plan says extractions provided by oral surgeons, 
periodontists, endodontists, other dental specialists, or non-network general dentists 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 Plans coverage rules apply in this case. The 2022 health plan contract 
says that services must be performed by a participating general dentist. Extractions by an oral surgeon are not 
covered. Therefore, we decided that the Plan does not have to pre-approve the dental extraction of tooth #29 
(CPT code D7140) to be provided by an out-of-network oral surgeon.