Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery 
bypass grafting. The enrollees medical problems are stable. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core buildup, including any pins 
when required (D2950) for tooth #2 and tooth #3. 
 
You asked the Plan to pre-approve a crown and a core buildup. You say that you had a crown done a few years 
ago and you have a gap between your teeth. You went back to the provider who did the crown, but the issue 
was not fixed. You would like to see a new provider to get the issue resolved. The Plan denied your request. 
The Plan says this service exceeds the maximum count allowed per period. 
 
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 a crown and a 
core buildup per tooth, once every five plan years.  
 
 
 
 
 
 We looked at the file and Medicare rules. The records show that you received a crown and a core buildup for 
tooth #2 and tooth #3 on December 2, 2020, therefore, you have exhausted your maximum benefit for these 
service. Based on this information, we decided that the Plan's rules for coverage of a crown and a core buildup 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and a 
core buildup, including any pins when required (D2950) for tooth #2 and tooth #3.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76700 provided on February 
10, 2022. 
 You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. 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 the ultrasound services coded 76700 provided on February 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the lower extremity 
rendered on December 17, 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 only one unit of code 73700 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 73700 is computed tomography, lower extremity; without 
contrast material. 
 
We find that CPT code 73700 is not supported in the medical record. Specifically, the records support only one 
unit of code 73700. Five further units are not supported in the records. 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 computed tomography (CT) scan of the lower extremity rendered on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested custom molded foot orthotics.
You asked the Plan to provide coverage for custom molded foot orthotics. In your appeal to the Plan and in a
letter sent directly to the IRE, you say that replacement molded foot orthotics are medically necessary for
treatment of plantar neuroma of the right foot. The Plan denied your request. The Plan states that you do not
meet the Medicare coverage criteria for molded orthotics and the Plan contract you are a member of does not
include supplemental coverage for foot orthotics. Maximus upheld the Plans decision however quoted the
incorrect service in the original letter. Maximus reopened the case and corrected the service reviewed.
The Plan is correct in this case. Medicare rules state that supportive devices for the feet (such as foot orthotics)
are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows
these same rules. The medical records do not indicate that you are using orthotics because you suffer from
diabetic foot disease. The medical records also do not show you wear a leg brace.
Although custom orthotics may be appropriate for your use, neither Medicare nor the Plan contract you are a
member of provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have
to provide coverage for the requested custom molded foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing provided on December 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service should be covered. The Plan denied 
your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the genetic testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the testing ordered and completed included multiple drug classes not clinically applicable to this case. 
The reviewer found that most of the testing was not directly clinically useful and was not described in the documentation to show they would lead to clinically improved outcome for the enrollee. Therefore, reviewer 
found that the GeneSight testing as ordered/completed will be considered excessive and not medically 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight testing provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 15, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that last summer you had standard individual x-
rays, not your whole mouth. You also say that on February 15, 2022 you had the full mouth x-ray and do not 
think you should be charged for the full spectrum because this was the first time you received the full spectrum. 
The Plan denied your request. The Plan says this procedure is covered once every 36 months. 
 
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, full mouth x-rays (including panoramic 
x-rays and complete series of intraoral x-rays) are limited to once every 36 months. The record shows that you 
received a complete series of intraoral x-rays (D0210) on June 21, 2021 and your full mouth x-rays benefit has 
been exhausted.  
 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 22, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral/facial photographic images (D0350 x 4), and 
panoramic x-ray (D0330) provided on February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that all these tests are required for new patients. You 
say that they are all part of your plan. You say that you should not be responsible for this bill if the tests are 
part of your plan. You also say that you were not informed that the services would not be covered. The Plan 
denied your request. The Plan says 1 panoramic or complete series x-ray is covered every 5 calendar years. The 
Plan says that the frequency limit has been exceeded. The Plan also says that oral/facial photographic image is 
not a covered service. 
 
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 and 1 panoramic or complete series x-
ray is covered every 5 calendar years, the frequency limit has been exceeded. The record shows that the Plan 
paid for a complete series x-ray that you received on the date of service in this case. Additionally, oral/facial 
photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the oral/facial photographic images (D0350 x 4), and panoramic x-ray (D0330) provided on 
February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) and 
comprehensive oral evaluation (D0150) provided on November 30, 2021, and December 16, 2021. 
 
You asked the Plan to pay for the incomplete endodontic therapy and comprehensive oral evaluation. You say 
that you had to see the endodontist to find out about the decay. You also say that you would like to know why 
procedures that have to be performed prior to an actual root canal are not part of the covered benefit. The Plan 
denied your request. The Plan says the incomplete endodontic therapy is not a covered benefit under your 
dental plan. The Plan also says that the comprehensive oral evaluation exceeds the frequency limitation in 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, incomplete endodontic therapy 
(D3332) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on October 8, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the incomplete 
endodontic therapy (D3332) and comprehensive oral evaluation (D0150) provided on November 30, 2021, and 
December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81162, 81206, 
81301, and 81311) provided on September 9, 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. 
 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): 81162, 81206, 81301, and 81311) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 fillings provided on January 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that the enrollment packet indicates that the plan 
will reimburse up to a maximum of $1,000 for dental services. You say that your claim total was $563. You 
also say that you should be reimbursed. The Plan denied your request. The Plan says fillings are not listed as 
covered 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 fillings are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3 fillings provided 
on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2790) provided by a network provider on 
January 5, 2022. 
 
You asked the Plan to pay for the crown (D2790). You say that you have the enhanced coverage and fillings 
are covered at 100% and crowns are covered at 50% The Plan denied your request. The Plan says you have 
been asked to pay the correct cost sharing amount. 
 
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 crown (D2790) is covered under 
this benefit with a 50% coinsurance with a network provider. You have been asked to pay $447.50 which is 
50% of the allowed amount. The allowed amount is $895. ($895 x 50% = $447.50). Therefore, we decided that 
the Plan does not have to pay for the crown (D2790) provided by a network provider on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation (D9222, D9223) provided by a network 
provider on December 28, 2021. 
 
You asked the Plan to pay for the deep sedation (D9222, D9223). You say that you would like to know why the 
sedation procedure was charged twice and you would like to be reimbursed if you were overcharged. The Plan 
denied your request. The Plan says the extractions are covered benefits with 50% coinsurance, and the deep 
sedation 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 deep sedation services 
(D9222, D9223) are not among those covered under this benefit. The record shows the deep sedation is billed 
in 15-minute increments and you received 45 minutes of sedation. Therefore, we decided that the Plan does not 
have to pay for deep sedation (D9222, D9223) provided by a network provider on December 28, 2021.
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 prophylaxis (D1110) provided on October 21, 2020 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
were never notified that your dentist had to be in Medicare in order to be reimbursed. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
The Plan also says that it was verified that the treating provider is not eligible for payment under Medicare 
guidelines. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis 
(D1110) provided on October 21, 2020 by a Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pharmacogenetic testing coded as 81238, 81220, 
81225, 81227, 81230, 81355, 81241, 81291, 81240 and 81291 provided October 1, 2021. 
 You asked the Plan to pay for the laboratory services. You say that please see attached medical records 
supporting billed charges. The Plan denied your request. The Plan says does not meet coding standards. Does 
not meet Medicare NCD/LCD criteria. 
 
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 find that the CPT codes are not supported in the medical record. Specifically 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. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for molecular 
pharmacogenetic testing coded as 81238, 81220, 81225, 81227, 81230, 81355, 81241, 81291, 81240 and 81291 
provided October 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are limited by your baseline function and new non-weight 
bearing status. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 
level of care such as home health or long-term care. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, zoledronic acid. The reviewer found that there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).