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

 
We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided on September 6, 2022, 
to September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should 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 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 August 18, 2022. 
Therefore, we decided that the Plan does not have to pay for panoramic x-rays (D0330) provided on September 
6, 2022, to September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the limited oral 
evaluation (D0140), intraoral radiographic images (D0220), bitewings (D0270), a cleaning (D1110), and core 
buildup (D2950) for tooth #12 provided on October 26, 2022, and November 14, 2022. 

You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services and 
have provided the proper documentation that was requested. The Plan denied your request. The Plan says your 
benefit for the periodic oral evaluation, intraoral radiographic images, bitewings, and cleaning has already been 
exhausted. Also, the denial of payment for the limited oral evaluation and core buildup is correct because they 
are 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, certain limitations apply. The record 
shows that the Plan paid for 2 periodic oral evaluations on April 28, 2022, and November 12, 2022; therefore, 
your benefit for the periodic oral evaluation was exhausted on the date of service of November 12, 2022. The 
record also shows that the Plan paid an intraoral radiographic image on April 28, 2022; therefore, your benefit 
for the intraoral radiographic image was exhausted on the date of service of April 28, 2022. The record also 
shows that the Plan paid a set of bitewings on April 28, 2022; therefore, your benefit for the bitewings was 
exhausted on April 28, 2022. The record also shows that the Plan paid for 2 cleanings on April 28, 2022, and 
November 14, 2022; therefore, your benefit for the cleaning was exhausted on November 14, 2022. The limited 
oral evaluation and core buildup are not covered under the Plan's dental benefit. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), the limited oral evaluation (D0140), 
intraoral radiographic images (D0220), bitewings (D0270), a cleaning (D1110), and core buildup (D2950) for 
tooth #12 provided on October 26, 2022, and November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) x4 provided on January 10, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial. The Plan denied 
your request. The Plan says this service is not covered under your 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. 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) is not covered under the Plans dental benefits. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) x4 provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator generator (C1767). 
 
You asked the Plan to pre-approve an implantable neurostimulator generator. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 implantable neurostimulator 
generator. Our reviewer says that the services are not medically necessary. Our physician reviewer found a 
successful trial of spinal cord stimulator (SCS) is required before permanent placement. Therefore, the 
permanent placement is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable neurostimulator generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantable neurostimulator generator (C1767).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the test strips provided from July 4, 2022, 
to October 17, 2022. 
 
You asked the Plan to waive the copayments for the test strips. You say that the strips should be fully covered. 
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 a $30 
copayment for in-network Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay a $30 copayment for each test strip provided on July 4, 2022, August 22, 2022, 
and October 17, 2022. You have been asked to pay a total of $90 ($30 copayment x 3 items = $90). These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for the test strips provided from July 4, 2022, to October 17, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 63053 rendered on December 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 63053 is "Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody 
arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary 
procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite an L3 
laminectomy with facetectomy, foraminotomy, and decompressing the L3 nerve roots was performed using a 
combination of high-speed bur, curettes, Kerrisons, Penfield dissectors, nerve blocks, and pituitary rongeur. 
This was above and beyond the necessity for interbody fusion. Similarly, L4 decompression, decompressing 
the L4 nerve roots was performed in a similar fashion.  Cortical screw instrumentation was then performed 
starting in front of the pars of L3 bilaterally. Pedicle screws were placed bilateral L3 as well as bilateral L4. 
Therefore, the records do support CPT 63053 in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 63053 rendered on December 14, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. Iliac crest bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 11, 2022, billed with 
code 81347. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 11, 2022, billed with code 81347.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311), and gel pads (K0108) for the enrollee.
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and gel pads. You say that these items are medically necessary. The Plan denied your request. The Plan says that the member's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and electronic connection. Our Medical Director states that the documentation does not support that the enrollee in this case has a medical need to control the power options through a joystick. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an expandable controller, harness and electronic connection. We looked at this physician's review, the file, and Medicare rules. The gel pads at issue in this appeal do not serve a purpose that is primarily medical in nature. The gel pads are available to the general public and would be helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection, and gel pads have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311), and gel pads (K0108) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (code 99285) provided to the enrollee on June 9, 2022.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that the provider billed code 30903 for date of service June 9, 2022. This a minor surgical code and is as defined on the Physician Fee Schedule. Global Days are "000". The provider also included code 99285 on the same claim, without a qualifying modifier. Per the Medicare guidelines under MLN ICN 907166, the initial evaluation for minor surgical procedures and endoscopies are always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier "-25" is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure. The Plan also notes per the Medicare Claims Processing Manual Chapter 12, Section 40.1 "C" , visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. The Plan notes the provider did not bill correctly as code 99285 is included in the minor procedure code 30903.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim was not submitted with the appropriate modifier that would show this was a separate and distinct service not related to the global surgery claim. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (code 99285) provided to the enrollee on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for You asked the Plan to pay for laboratory services (83718 and 83721) provided to the enrollee on October 21, 2021.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided documentation to show the overturned codes were paid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Code 83721 is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to bypass the edit. In addition, we have confirmed that code 83718 is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore note payable. 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 services described by procedure code(s) 83718 and 83721.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 36248 and 37247 provided to the enrollee on October 25, 2021.
You asked the Plan to pay for procedure codes 36248 and 37247. You say that these services were medically necessary. The Plan denied your request. The Plan says that procedure codes 36248 and 37247 were billed without an appropriate primary procedure code.
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 procedure codes 36248 and 37247 are add-on codes and have not been billed with an appropriate primary procedure code. 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 codes 36248 and 37247 provided to the enrollee on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 11, 2022, to December 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your primary care 
provider convinced you to stay longer, resulting in an additional day of your stay you feel you should not 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 a $150 
copayment per day for days 1-7 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment for any additional days of the same inpatient stay. 
 
You have been asked to pay a $150 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $300 ($150 copayment per day x 2 days = $300). 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 the inpatient hospital stay provided from December 11, 
2022, to December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional pontic and retainer crown (D6740, 
D6245). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 with the plans authorization from date of 
service March 16, 2023 to June 14, 2023. Therefore, we decided that the Plan does not have to pre-approve an 
additional pontic and retainer crown (D6740, D6245).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on November 01, 2022, to 
November 22, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on November 01, 2022, to November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing feature (E2301) and related 
accessories. 
 You asked the Plan to pre-approve a power standing feature and related accessories. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says that power standing features are 
convenience items and are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power standing feature (E2301) and related accessories.