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

 
We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81206, 81235, 
and 81321) provided on June 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81206, 81235, and 
81321) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 2 Power Wheelchair for the enrollee.
You asked the Plan to provide coverage for a Group 2 Power Wheelchair. You say that the requested power
wheelchair is medically necessary. The Plan denied your request.
The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 2 power
wheelchair. The Maximus Physician Reviewer determined that the requested group 2 power wheelchair is
medically reasonable and necessary in this case. The Plan requested a reopen and argues the records show the
enrollee can stand and ambulate. It is unknown how far the patient can ambulate and what the strength
measurements of the limbs are, only that it is limited by an undefined disease. There is no documentation that
alternatives such as a walker, cane or manual wheelchair are not sufficient to complete Mobility Related
Activities of Daily Living (MRADLS). It is unknown if there are uncompensated conditions that limit ability to
safely operate a power or regular wheelchair, like impaired vision, cognition, or judgment. A detailed driving
analysis is needed. It is unclear whether further physical decline in the patient or surgical intervention is
anticipated. It is unknown whether the physical layout, surfaces, and obstacles in the home permit safe
operation of a power wheelchair. A timely physician Face-to- Face evaluation in the Medicare prescribed
manner is not documented.
Our Medical Director has concluded that the Plan is correct in this case. The documentation is insufficient to
demonstrate that all the coverage criteria for a Group 2 power wheelchair were met 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 a Group 2 Power Wheelchair have not been met. Therefore, we decided that the Plan does not
have to provide coverage for a Group 2 Power Wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve knee-shin system flexion swing/stance (code L5828), stance 
flexion (L5845), fluid stance extension (L5848), microprocessor control feature (L5856), and above knee or hip 
disarticulation (L5850) lower limb prosthetic components. 
 You asked the Plan to pre-approve lower limb prosthetic components. You say that you are appealing this 
denial. The Plan denied your request. The Plan says that the denial of authorization for these components is 
correct, because a microprocessor knee is not necessary for the approved prosthesis. 
 
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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found all of the needed information including you being a K3 level ambulator as well 
as why the microprocessor system is necessary have been attested to by your treating physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have been met. Therefore, we decided that 
the Plan has to pre-approve knee-shin system flexion swing/stance (code L5828), stance flexion (L5845), fluid 
stance extension (L5848), microprocessor control feature (L5856), and above knee or hip disarticulation 
(L5850) lower limb prosthetic components.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a power scooter with safety flag for the
enrollee.
You asked the Plan to provide coverage for a power scooter with safety flag. You say that a power scooter is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial for a lack of medical records. The Plan requested a reopen and submitted
the required medical records.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that a power mobility
device will not be covered if all the required criteria are not met. The medical records and the statements made
regarding the enrollee's mobility in the home are not consistent. The documentation provided does not show
the enrollee meets all the required criteria for a power mobility device inside the home. Medicare does not
cover a power mobility device for use outside of the home. A safety flag would never be covered by Medicare
under any circumstance. Therefore, we decided that the Plan does not have to provide coverage for a power
scooter with safety flag for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 31, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this panel should be billed with one single code. As such, only 11 of 
the 13 line items will be paid. 
 The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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 NGS panel was billed with multiple codes instead of a single 
panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on August 31, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions provided by an out-of-network provider on 
October 14, 2021. 
 
You asked the Plan to pay for dental extraction. You say that these services needed to be provided. You say 
that these services were medically necessary. The Plan denied your request. The Plan says this claim has been 
processed correctly. 
 
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 Plan covers up to a $1,000 
maximum benefit allowance for covered dental benefits. 
 
We looked at the file and Medicare rules. The Plan has approved and paid $1,000 towards the dental extraction 
provided. The remaining balance has been correctly denied. Based on this information, we decided that the Plan's rules for coverage of dental extraction have not been met. 
Therefore, we decided that the Plan does not have to pay for dental extractions provided by an out-of-network 
provider on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid testing services provided on November 30, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
not covered as a screening tool. 
 
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 records do not show that the testing services were ordered to delineate the presence or absence of 
hormonal abnormalities of the thyroid. Medicare does not cover this testing for screening purposes. Therefore, 
we decided that the Plan does not have to pay for the thyroid testing services provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), resin-based composite - two 
surfaces, posterior (D2392), resin-based composite - one surface, posterior (D2391), and unspecified 
preventive procedure, by report (D1999) provided September 28, 2021, to November 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam, bitewing x-rays, dental cleaning, fillings and unspecified 
preventative procedures. You say that you were not told that this provider was no longer in-network. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON. 
 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 Plan covers the periodic 
oral exam, bitewing x-rays, dental cleaning and fillings when provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the periodic oral exam bitewing x-rays, dental cleaning and fillings have not been met. Though the Plan offers 
dental benefits in excess of Medicare coverage, the unspecified preventative procedure is not among those 
covered services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), resin-
based composite - two surfaces, posterior (D2392), resin-based composite - one surface, posterior (D2391), and 
unspecified preventive procedure, by report (D1999) provided September 28, 2021, to November 1, 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 a period oral evaluation (D0120) provided by a participating 
provider on December 29, 2021. 
 
You asked the Plan to pay for a period oral evaluation. You say that due to COVID there was scheduling 
disruptions. You say that you feel like this should be covered. The Plan denied your request. The Plan says this 
claim has been correctly denied. 
 
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 Plan covers two period 
oral evaluations per calendar year. 
 
We looked at the file and Medicare rules. An oral evaluation was provided on January 4, 2021, and June 15, 
2021.Based on this information, we decided that the Plan's rules for coverage of a period oral evaluation have 
not been met. Therefore, we decided that the Plan does not have to pay for a period oral evaluation (D0120) 
provided by a participating provider on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneers (D2962) provided by a participating 
provider. 
 
You asked the Plan to pre-approve labial veneers. You say that these veneers are necessary because your teeth 
have started to erode. The Plan denied your request. The Plan says this claim has been correctly denied. 
 
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 
labial veneers (D2962) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth #21 and #26. 
 
You asked the Plan to pre-approve the crowns. You say that this is medically necessary. The Plan denied your 
request. The Plan says the x-rays do not show a cavity under the old cap. 
 
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 Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
provided did not include diagnostic radiographs nor a narrative indicating why replacement crowns are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain/ceramic crown for tooth #21 and #26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 49905 is not supported. 
 
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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). 
 We find that CPT code 49905 is not supported in the medical record. Specifically, there is no documentation of 
an intra-abdominal omental flap. 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 pay for the surgical 
services rendered on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and teeth cleaning, all quadrants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the x-rays show no obvious bone loss, and no evidence of periodontitis. 
 
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 Plan covers the services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the provided 
records indicate abnormal pocket depth measurements in three of the four quadrants (UR, LR and UL). The 
radiograph shows minimal bone loss in the area of #18 only, and this tooth is the only tooth in the quadrant 
with any abnormal pocket readings. The remainder of the bone levels appear to be essentially normal with no 
tartar noted on x-rays. The code D4341 is reserved for situations where there are four or more teeth 
periodontally involved in a quadrant exhibiting a loss of clinical attachment evidenced by loss of supporting 
bone. As there is only one tooth in the entire dental arch that shows attachment loss (#18), the code of D4341 is 
not applicable. In this instance, there are less than four teeth in any quadrant showing radiographic loss of bone support, and therefore the Plan criteria has not been met. There is no necessity for the D4341 procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve deep gum and teeth cleaning, all quadrants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve the porcelain/ceramic crown (D2740). You say that this service should be 
covered under your plan. The Plan denied your request. The Plan says the pre-determination processed 
correctly to allow benefits at the least costly method of treatment, and pay at the alternate benefit of a porcelain 
fused to predominantly base metal crown (D2751). 
 
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, if a method of treatment is more costly 
than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be 
responsible for the remaining balance. You have been approved to receive treatment under the less costly 
method of a porcelain fused to predominantly base metal crown (D2751), and you will be responsible for the 
difference between the cost for this service and the porcelain/ceramic crown (D2740), which you requested to 
receive. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300), a power wheelchair accessory, expandable controller, including all related electronics and mounting 
hardware (E2377), a power wheelchair accessory, harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (E2313), a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), a control & toggle 
switch (K0108), a wheelchair accessory, positioning belt/safety belt/pelvic strap (E0978) and an orientation 
wedge (K0108). 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has paralysis and leaving 
the member without this treatment could jeopardize her quality of life and life itself. The Plan denied your 
request. The Plan says the requested special power wheelchair (group3 power wheelchair) and some of the 
requested accessories are medically necessary for you and will be covered. However, some items remain 
denied. The Plan also says the seat lift does not service a primary medical purpose and is not covered. The 
requested joystick module controller display is included with the requested controller. The requested seat belt 
and the requested cushion are already included with the approved wheelchair and cannot be billed separately. 
 
The file shows that some of the items requested are medically necessary and the Plan has approved them. Some 
wheelchair accessories are not covered and do not have a medical purpose. The file also shows that some 
accessories are already approved with the wheelchair and cannot be billed separately. Therefore, we decided 
that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system (E2300), a 
power wheelchair accessory, expandable controller, including all related electronics and mounting hardware 
(E2377), a power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, 
connectors and mounting hardware (E2313), a power wheelchair accessory, electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), a control & toggle switch 
(K0108), a wheelchair accessory, positioning belt/safety belt/pelvic strap (E0978) and an orientation wedge 
(K0108).