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

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) for tooth #3 provided on 
December 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service with 
the proper documentation from the dental office. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the bone replacement graft 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) for tooth #3 provided on December 9, 2022.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 74018 billed for date of service May 19, 2022.
You asked the Plan to pay for procedure code 74018. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for code 74240. Maximus overturned the Plan's denial. The Plan requested a reopening and provided proof that they covered procedure code 74240.
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 74018 is a column II code to column I code 74240. 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 74018 billed for date of service May 19, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes procedure codes U0003 and 
U0005. We decided that the Plan does not have to pay for the services described by procedure codes 87498, 
87502, 87634, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service October 11, 2022. The Plan says that the 
coding is not supported. 
 
We decided that the Plan has to pay for the services described by procedure codes procedure codes 
U0003 and U0005.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the CPT Code Manual definition of code U0003 is Infectious agent detection by nucleic acid; 
severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]). The definition 
of code U0005 is infectious agent detection by nucleic acid; severe acute respiratory syndrome coronavirus 2 
(sars-cov-2) (coronavirus disease [covid-19]). (List separately in addition to either code U0003 or U0004) 
 
We looked at the file and the rules. The lab testing shows that Covid-19 testing was provided. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Specifically, the Plan did not make an appeal decision for the codes listed in this section. The 
Plan did not provide a denial rationale for these services. The denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure codes procedure codes U0003 and 
U0005 billed for date of service October 11, 2022.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 87498, 
87502, 87634, and 87798. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a respiratory panel test was provided. We looked at the file, and Medicare rules. The panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure codes 87498, 87502, 87634, and 87798 billed for date of service October 6, 202. 
 
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: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for hospice services provided on May 1, 2023. 
 
You asked the Plan to pay for hospice services. You say that that the claims have been corrected several times 
and should not be denied for timely filing. The Plan denied your request. The Plan says that the claim was not 
filed timely. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for services furnished on or after January 
1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospice services have been met. Specifically, the provider has provided proof of submitting the 
claim on time back on June 1, 2021. Therefore, we decided that the Plan has to pay for hospice services 
provided on May 1, 2023.  
 
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 waive the copayment for inpatient services provided on January 8, 
2023, to January 27, 2023. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you disagree with the 
copayment. 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 $250 
copayment for inpatient services.  
 
You have been asked to pay a $250 copayment for inpatient services. This item/service falls within the 
inpatient services 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 inpatient services 
provided on January 8, 2023, to January 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found care was 
provided to an established enrollee. No physical examination is documented. The medical decision making is 
not of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) and medicaments (D9630) 
provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was necessary that you have a deep cleaning 
done. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
the gingival irrigation and medicaments 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, 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 irrigation (D4921) and medicaments (D9630) provided on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility.  
 
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 the enrollee is medically stable and does not need, medical monitoring by a physician 
with close supervision three times per week at a minimum. The document does not support medical necessity 
for admission to an IRF. The enrollee has no medical complexity currently with no acute rehabilitation nursing 
needs to warrant an admission to an IRF. Even though the enrollee would benefit from physical therapy and 
occupational therapy, the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of allogeneic cellular. 
 
You asked the Plan to pre-approve injection of allogeneic cellular. You say that it is medically necessary. The 
Plan denied your request. The Plan says there is not enough medical evidence to support that treatment with the 
injection will be effective for the management of lower back pain. 
 
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 injection of allogeneic cellular. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered investigational and not medically necessary for 
the treatment of degenerative disc disease. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of allogeneic cellular have not been met. Therefore, we decided that 
the Plan does not have to pre-approve injection of allogeneic cellular.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatism correcting intraocular lens. 
 
You asked the Plan to pre-approve astigmatism correcting intraocular lens. You say that you said you don't 
understand why sight would not be considered important. The Plan denied your request. The Plan says 
Medicare does not cover eyeglasses or contact lenses. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve astigmatism 
correcting intraocular lens.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that the item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer 
found the item is not experimental and the enrollee's medical record supports her individual need for the 
requested orthosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthosis have been met. Therefore, we decided that the Plan has to 
pre-approve a MyoPro orthosis (L8702).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for and will 
benefit from an IRF admission. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (scooter) (K0812). 
 
You asked the Plan to pre-approve a scooter. The Plan denied your request. The Plan says the requested 
powered operated vehicle (scooter) is not medically necessary under Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 a scooter. Our reviewer says that you 
do not meet the criteria for coverage. Our physician reviewer found you have chronic functional loss, and the 
physical therapy evaluation indicates you are using a manual wheelchair in the home to complete self-care 
activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (scooter) (K0812).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the polarization, and the polycarbonate 
lens provided on June 1, 2023. 
 
You asked the Plan to pay for the progressive lens, the polarization, and the polycarbonate lens. You say that 
you are requesting payment that your benefit allows. The Plan denied your request. The Plan says the 
progressive lens was denied because the benefit maximum had been reached and the polarization and 
polycarbonate lens are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when one pair of standard lenses frames every year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for lenses on January 6, 2023, which 
exhausted the benefit. Also, the polarization and the polycarbonate are considered upgrades, which are not 
covered benefits. Based on this information, we decided that the Plan's rules for coverage of the progressive 
lens, the polarization, and the polycarbonate lens have not been met. Therefore, we decided that the Plan does 
not have to pay for the progressive lens, the polarization, and the polycarbonate lens provided on June 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor full arm (E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that you are 
requesting reconsideration and have provided medical records for review. The Plan denied your request. The 
Plan says the records do not show at least four-week trial of daily, multiple-hour home usage of the basic pump 
or swelling extending onto the chest and trunk. The enrollee does not meet criteria for approval of the PCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor full arm (E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you were approved to a provider back in 
October 2021. You requested the authorization again. The Plan denied your request. The Plan says the 
requested service is not approved because review of medical records does not support medical necessity for 
care with a highly specialized tertiary care 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 16, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for 
code 99285. 
 
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 99284 is a column II code to column I code 99285. Code 99284 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 99284 
billed for date of service May 16, 2023.