Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180), panoramic x-ray (D0330) and bitewings - two radiographic images (D0272) provided on July 
14, 2023. 
 
You asked the Plan to pay for comprehensive periodontal evaluation - new or established patient. You say that 
this should be covered. The Plan denied your request. The Plan says this 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 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 
comprehensive periodontal evaluation - new or established patient (D0180), panoramic x-ray (D0330) and 
bitewings - two radiographic images (D0272) provided on July 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to regain their prior level of function. The Plan denied your request. The Plan says when the 
enrollee is ready to leave the hospital, they can receive this care in another setting such as a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 enrollee would greatly benefit from additional 
time in SNF prior to discharge home. The Plan denied your request. The Plan says the enrollee has not 
completed their course of treatment in the inpatient rehabilitation facility. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage.  Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollee can complete their current course of therapy, before being discharged to a lower level of 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 pay for the self-administered drugs from April 5, 2023, through 
April 27, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs from 
April 5, 2023, through April 27, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections. 
 
You asked the Plan to pre-approve trigger point injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 trigger point injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found provided records in this case do 
not document any restricted range of motion on examination of the shoulder area or back. Records also do not 
document any of the minor criteria required for diagnosing trigger points including reproduction of referred 
pain pattern by stimulating the trigger point, or altered sensation by pressure on the tender spot, or local 
response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot or pain 
alleviated by stretching or injecting the tender spot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trigger point injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger point injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88341 provided to the enrollee on October
31, 2022.

You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that procedure code 88341 is an add-on code
that was billed without an appropriate primary procedure code. Maximus overturned the Plan's denial. The
Plan requested a reopening and stated that this procedure cannot be covered because the primary code was not
paid. The Plan is correct in this case. The file indicates primary code 88342 was not paid. 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 code 88341 is an add-on code and has not been billed with an
appropriate paid 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 code 88341 provided to the
enrollee on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, oral hygiene instructions, periodic oral 
evaluation, and bitewing x-rays (D1110, D1330, D0120, D0274) provided on January 26, 2023. 
 
You asked the Plan to pay for 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 the services denied correctly as the claim was 
filed untimely. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The records 
provided show that the claim for payment was submitted on August 16, 2023. This is more than 120 days from 
January 26, 2023. Therefore, the rules for coverage have not been met and the Plan does not have to pay for a 
cleaning, oral hygiene instructions, periodic oral evaluation, and bitewing x-rays provided on January 26, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning, oral hygiene instructions, periodic oral 
evaluation, and bitewing x-rays (D1110, D1330, D0120, D0274) provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endosteal implants, bone grafts, and extractions 
(D6010, D7210, D6104) provided on June 5, 2023. 
 
You asked the Plan to pay more for 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 on date of service June 5, 2023. Therefore, 
we decided that the Plan does not have to pay more for endosteal implants, bone grafts, and extractions 
(D6010, D7210, D6104) provided on June 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on June 12, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies do not require separate 
authorization. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on June 12, 2023, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for 
treatment of central sleep apnea; complete system (0424T). 
 
You asked the Plan to pre-approve insertion or replacement of neurostimulator system. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve insertion or replacement of 
neurostimulator system. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, use 
of the Remede phrenic nerve stimulation system would not be appropriate or medically necessary in this 
enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of neurostimulator system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator 
system for treatment of central sleep apnea; complete system (0424T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on July 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary to have the x-ray 
done because you were experiencing pain in your left tooth area. 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 the Plan paid for the intraoral complete series of radiographic images (D0210) on November 17, 2021; 
therefore, your benefit for the requested item or service was exhausted on the date of service of November 17, 
2021. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on July 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
December 3, 2022, to December 4, 2022.

You asked the Plan to pay for the home health services. You say that you have billed the services at issue
correctly. The Plan denied your request. The Plan says that the type of bill was incorrect. Maximus overturned
the Plan's denial. The Plan requested a reopening based on the fact the claim was submitted with the incorrect
type of bill code. The Plan was correct in this case, the claim was not filed with the correct type of bill code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from December 3, 2022, to December 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pre-approve a crown. You say that your plan only covers steel crowns that are not 
suitable for adults. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental 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 pre-approve a 
crown - porcelain fused to high noble metal (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 8, 2023. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says procedure codes 99100 
and 99140 are considered bundled and 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 procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that if you are unable to get the physical therapy 
while in Florida, it will set you back. You also cannot afford to pay for the entire visit. The Plan denied your 
request. The Plan says you must use a network provider for your medical care. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided on April 27, 2023, to, April 30, 2023. 
 You asked the Plan to pay for SNF care. You say that hospice was revoked on April 23, 2023. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 23, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for SNF)care provided 
on April 27, 2023, to, April 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 26, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would appreciate prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over 
the counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex care needs. The Plan denied your request. The Plan says the enrollee can receive the 
care needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that if it were not for the chiropractic services you would 
have gone to the emergency room. The Plan denied your request. The Plan says the only covered chiropractic 
service is manual manipulation of the spine. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 11, 2023.