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

 
We decided that the Plan does not have to pay for the gingival inflammation (D4346) provided on March 11, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the enrollee went to an in-network dentist, and 
you would like the Plan to pay for the dental service. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the gingival inflammation 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 the 
gingival inflammation (D4346) provided on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not meet the clinical requirements to be approved. 
 
  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that enrollee does not meet the age requirement. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you were denied Inogen but 
had gotten approved 6 months ago and was told you were on the waiting list all this time. The Plan denied your 
request. The Plan says the Plan is currently providing the enrollee with the most appropriate equipment that 
meets their medical needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable D-tanks oxygen cylinders. You were provided with standard oxygen 
systems, a home oxygen concentrator and a home-fill oxygen system with portable D-tanks oxygen cylinders, 
on March 29, 2022. The portable D-tanks oxygen cylinders serves the same purpose as the portable oxygen 
concentrator. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator 
(E1392).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of osteoporosis. The documentation does not support that the enrollee has a 
history of osteoporotic fracture or has tried and failed zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve levator resection services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve levator resection services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
levator resection services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Part B prescription drugs provided on July 
8, 2022. 
 
You asked the Plan to waive the copayment for Part B prescription drugs. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B Prescription Drugs. The allowed amounts of these Medicare Part B drugs total 
$3,089.95, resulting in a total coinsurance amount of $617.97. 
 
You have been asked to pay 20% coinsurance for Part B prescription drugs. This item/service falls within the 
Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
Part B prescription drugs provided on July 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 14060 billed for date of service July 14, 
2021. 
 
You asked the Plan to pay for procedure code 14060. You say that please see attached medical records to 
review and reconsider this claim for payment as it was medically necessary. The Plan denied your request. The 
Plan says payment for code 14060 is bundled into payment for the primary procedure. 
 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 14060 
is considered incidental/inclusive to the primary procedure. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 14060 billed for date of service 
July 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 28, 2022, through 
April 22, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that all of the claims should have been accepted by the 
Plan and you should be reimbursed for 8 claims. The Plan denied your request. The Plan says Medicare does 
not cover behavioral health services performed by a Marriage and Family Therapist. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, a Marriage and Family Therapist is not eligible for 
payment. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 
28, 2022, through April 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0483) provided on August 20, 2021. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
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. In this case, the CPT Code Manual definition of 
code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records support that 22 or 
more drug classes have been tested, including Alkaloids, Amphetamines, Antidepressants-serotenergic class, 
Antidepressants-tricyclic and other cyclicals, Antidepressants-not otherwise specified, Antipsychotics, 
Barbituates, Benzodizepines, Buprenorphine, Cannabinoids-natural, Cocaine, Fentanyls, Gabapentin-non-
blood, Heroin, Ketamine and Norketamine, Methadone, Methylenedioxyamphetamines, Methylphenidate, 
Opiates, Opioids and opiate analogs, Oxycodone, Sedative Hypnotics, Skeletal muscle relaxants, Tapentadol, 
and Tramadol. Based on this information, we decided that Medicare rules for coverage of procedure code 
G0483 have been met. Therefore, we decided that the Plan has to pay for the drug testing (G0483) provided on 
August 20, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission would greatly improve the 
enrollee's current quality of life to allow them to resume their previous independence. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee may 
need physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 30, 2022, to July 10, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there were no identifiable skilled nursing or skilled therapy service needs. The 
enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from June 30, 2022, to July 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that enrollee would benefit from inpatient rehabilitation 
services due to their medical complexity. The Plan denied your request. The Plan says the enrollee's needs can 
be met at a lower level of care such as skilled nursing facility (SNF), home with home health services or home 
with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) for the lower left, lower right, 
upper left, and upper right quadrants, the localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue, per tooth (D4381) for teeth numbers 22, 23, 25, 26, 29, 7, 10, 13, 27, 31, 
11, 3, 4, 6, 15, 20, 32, 2, 19, and 18, and drugs or medicaments dispensed in the office for home use (D9630) 
provided on September 9, 2022. 
 
  You asked the Plan to pay for gingival irrigation (D4921) for the lower left, lower right, upper left, and upper 
right quadrants, the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381) for teeth numbers 22, 23, 25, 26, 29, 7, 10, 13, 27, 31, 11, 3, 4, 6, 15, 20, 
32, 2, 19, and 18, and drugs or medicaments dispensed in the office for home use (D9630). You say that that 
this is excessive billing and unnecessary. The Plan denied your request. The Plan says according to the 
member's 2022 EOC, there is no coverage for these services. 
 
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) for the lower left, lower right, upper left, and upper right quadrants, the localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) for teeth 
numbers 22, 23, 25, 26, 29, 7, 10, 13, 27, 31, 11, 3, 4, 6, 15, 20, 32, 2, 19, and 18, and drugs or medicaments 
dispensed in the office for home use (D9630) provided on September 9, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review. 
 
Your complaint about the potential misinformation given to you by the provider and the potential unnecessary 
treatment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom abutment on tooth #19 (D6057) and an abutment 
supported crown on tooth #19 (D6061) provided on July 7, 2022. 
 
You asked the Plan to pay for an abutment and a crown. You say that crowns are covered services. The Plan 
denied your request. The Plan says a custom abutment (D6057) and an abutment supported crown (D6061) 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 a custom 
abutment on tooth #19 (D6057) and an abutment supported crown on tooth #19 (D6061) provided on July 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for injection into skin growth, 1-7 growths 
provided on July 25, 2022. 
 
You asked the Plan to waive the deductible for injection into skin growth. You say that you don't understand 
why you have to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $218.84 
for Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory 
surgical centers. This applied toward to your $750 deductible.  
 
You have been asked to pay $218.84 for injection into skin growth. This item/service falls within the 
Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible for injection into skin growth, 1-7 
growths provided on July 25, 2022.