Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on November 15, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met as the records submitted were incomplete. Maximus overturned the Plans denial stating the services were necessary. The Plan requested a reopen and stated the issue was not medical necessity, but the incomplete data submitted with the medical records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. The rules also say that the medical records provided must support the services billed. The medical records provided are not properly signed and dated for the date of service listed on the claim. Therefore, we decided that the Plan does not have to pay for pain management services provided to the enrollee on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve an upper partial denture. You say that you would like this service covered. 
The Plan denied your request. The Plan says that the teeth in the radiograph are missing more than 50% of the 
bone supporting them. This would not establish a good long-term outcome for a partial denture. There is no 
clinical evidence to support medical necessity. 
 
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 an upper 
partial denture 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 an upper partial denture. Our reviewer 
says that an upper partial denture is medically reasonable and necessary. Our physician reviewer found that a 
review of the documentation indicates that the teeth to be used as abutments appear to have adequate bone 
support. The enrollee requires replacement of the missing maxillary teeth to provide adequate masticatory 
function. Thus, the upper partial denture is medically necessary. 
 
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 an upper partial denture have been met. Therefore, we decided that the Plan has 
to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on February 28, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on February 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic 
radiographic image (D0330) provided on March 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. 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 October 6, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a 
panoramic radiographic image (D0330) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 0037U provided on March 14, 
2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on June 25, 2019. There is no documentation to support testing on the billed 
date of service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
coded 0037U provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canals (D3320, D3330), core build up (D2950), and 
crowns (D2751) for teeth # 20 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
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 dental 
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 dental services. Our reviewer says 
that the requested dental services are not medically necessary. Our physician reviewer found the provided 
documentation indicates that tooth # 20 has a small to moderate size carious lesion. This it is not enough to 
warrant a crown or root canal treatment. The reviewer also found that tooth # 30 is intact and does not require a 
crown or root canal treatment. Given the lack of any significant structural loss on teeth # 20 and 30, the 
requested dental services would not be considered reasonable or necessary.  
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve root canals (D3320, D3330), core build up (D2950), and crowns (D2751) for teeth # 20 
and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided on April 18, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation (D7953). You say that you gave 
informed consent to allow for a bone-graft only if deemed medically necessary by the attending dentist. The 
Plan denied your request. The Plan says a bone replacement graft for ridge preservation (D7953) 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 bone 
replacement graft for ridge preservation (D7953) provided on April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have intensive or complex rehabilitation needs. Your wound care 
requires changes three times weekly and does not require physician review multiple times per week. You do 
not require IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #19 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the dentist is not able to do another filling because the 
tooth is broken too far down. The Plan denied your request. The Plan says that a crown (D2740) is not covered 
by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a 
crown on tooth #19 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement prosthetic legs and feet. 
 
You asked the Plan to pre-approve replacement prosthetics. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the 
requested items have not been met. 
 
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 replacement prosthetics. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that provided records do not document that the enrollee's present prostheses and feet have 
exceeded their reasonable useful lifetime or have been lost, stolen or irreparably damaged, or that there have been physiologic changes in the enrollee to meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement prosthetics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement prosthetic legs and feet.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of code 99284 billed for date of service April 
20, 2022. 
 
You asked the Plan to pay for a second unit of code 99284. You say that the patient had two separate visits on 
this date. The Plan denied your request. The Plan says only one unit of code 99284 is payable because the 
providers are in the same practice and of the same specialty. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one E/M service is provided on the 
same day to the same patient by the same physician or more than one physician in the same specialty in the 
same group, only one E/M service may be reported unless the evaluation and management services are for 
unrelated problems. 
 
In this case, you have billed two units of code 99284, one with modifier -25.  Modifier -25 is to be used for 
separate and distinct E/M encounters when the E/M visit occurs on the same date as a diagnostic 
medical/surgical or therapeutic service.  In other words, modifier 25 does not apply when no diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) is performed.  In this case, there is no 
evidence that the patient had a diagnostic or therapeutic medical procedure on this date.  In addition, the 
medical records indicate that for both visits, the patient was seen for the same condition (abdominal pain 
resulting from heroin withdrawal). So, while there may have been two separate visits on that date, the visits 
were not for unrelated issues. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a second unit of code 99284 have not been met. Therefore, we decided that the Plan does not have 
to pay for a second unit of code 99284 billed for date of service April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride treatment (D1206) provided on April 25, 2022. 
 
You asked the Plan to pay for the fluoride treatment. You say that you did not know the fluoride treatment was 
not covered. The Plan denied your request. The Plan says that fluoride treatment (D1206) is not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
fluoride treatment (D1206) provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood concentrate (D7921) for tooth #15 provided on May 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to cover this service. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because blood 
concentrate 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 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 blood 
concentrate (D7921) for tooth #15 provided on May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix glucose test strips (A4253). 
 You asked the Plan to pre-approve the True Metrix glucose test strips. You say that the requested strips are 
medically necessary. The Plan denied your request. The Plan says the requested brand is not covered under the 
plan's benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested brand of test strips is not covered under the plan. 
Based on this information, we decided that Medicare rules for coverage of the True Metrix glucose test strips 
have not been met. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test 
strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline of a denture (D5750) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the procedure was not to repair the denture only 
to do a proper fit of the denture. 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 of March 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a reline of a denture (D5750) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #14 (D2740) and core build up on tooth 
#14 (D2950) provided on May 11, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that these services should be covered. The 
Plan denied your request. The Plan says a crown (D2740) and core build up (D2950) are not covered by your 
dental benefits. The Plan also says that you have coverage for crown repairs but not a new crown. 
 
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 crown 
on tooth #14 (D2740) and core build up on tooth #14 (D2950) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) and bone grafts (D6104) 
provided by a participating provider. 
 
You asked the Plan to pre-approve endosteal implants and bone grafts. You say that you are in a lot of pain. 
The Plan denied your request. The Plan says the requested services are not covered 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 pre-approve 
endosteal implants (D6010) and bone grafts (D6104) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943), the mechanical traction therapy (97012), and the therapeutic activities (97530) provided on May 4, 2022 and May 20, 2022.
You asked the Plan to pay 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 under the enrollee's contractual policy or by Medicare.
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. Extra-spinal manipulative treatment is not a covered benefit. The records show that the services provided do not meet Medicare criteria for coverage of chiropractic services and therefore, are not covered under the Plan contract.
Therefore, we decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943), the mechanical traction therapy (97012), and the therapeutic activities (97530) provided on May 4, 2022 and May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and the localized delivery of 
antimicrobial agents (D4381) provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says gingival irrigation (D4921) and the localized delivery of 
antimicrobial agents (D4381) 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 gingival 
irrigation (D4921) and the localized delivery of antimicrobial agents (D4381) provided on June 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided April 
13, 2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that this test was medically 
necessary and is covered. The Plan denied your request. The Plan says this test is not covered by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that evidence does not support combinatorial PGx 
tests. 
 
We looked at the file and Medicare rules. GeneSight Psychotropic testing is a combinatorial PGx test. This type 
of test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the GeneSight 
Psychotropic testing (81479) provided April 13, 2022.