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

 
We decided that the Plan does not have to pay for oral exam (D0140), panoramic x-ray (D0330) and partial 
denture (D5422) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you looked at your coverages and the services 
you received should be covered by insurance. 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 that the Plan paid $370 for date of service February 16, 2023, $100 for date of service March 13, 2023, 
$500 for date of service March 28, 2023, $350 for date of service April 4, 2023, $180 for date of service July 
24, 2023 ($370 + $100 + $500 + $350 + $180 = $1,500). Therefore, your yearly maximum benefit of $1,500 
was exhausted on date of service July 24, 2023. Therefore, we decided that the Plan does not have to pay for 
oral exam (D0140), panoramic x-ray (D0330) and partial denture (D5422) provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that you need this for your condition. 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 US-IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. This would 
not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0861) and 
additional items and accessories (codes E2300, E2359, E1028, E2377, E2313, E1007, E2311, E2620, E2624, 
E1012, K0040, and E0955) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you understand that you are an OON provider, but are asking for an exception on this with a 
specialty configured power wheelchair. The Plan denied your request. The Plan says medically necessary care 
is available in network. 
 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. Though the Plan offers a POS 
benefit option, this is only for covered routine dental services. 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 a group 3 
standard power wheelchair (K0861) and additional items and accessories (codes E2300, E2359, E1028, E2377, 
E2313, E1007, E2311, E2620, E2624, E1012, K0040, and E0955) to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 2 power wheelchair with multiple power options 
(tilt/recline, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with multiple power options. You say that this 
is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a 
qualifying diagnosis causing mobility limitation for which a Group 3 power wheelchair is medically needed.  
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with multiple power 
options may be covered when certain 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 a Group 2 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 2 power wheelchair with multiple power 
options is medically necessary. Our physician reviewer found the provided records support that the enrollee is 
functionally non-ambulatory and cannot use a cane or walker for mobility. They cannot functionally propel a 
manual wheelchair due to upper extremity weakness and impaired cardiac and respiratory status due to chronic 
obstructive pulmonary disease (COPD) and heart failure. The provided records support that the enrollee cannot 
use a power scooter due to the impaired ability to transfer independently. The enrollee require a power seat that 
allows for pressure relief given their upper extremity weakness and impaired right shoulder range of motion 
due to rotator cuff tendinopathy. The enrollee requires a power articulating foot platform due to lower 
extremity edema and for positioning. Therefore, the reviewer found that the requested Group 2 power 
wheelchair with multiple power options is 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 a Group 2 power wheelchair with multiple power options have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 2 power wheelchair with multiple power 
options (tilt/recline, legrests) and accessories.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography (95870) provided on July 27, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that this was medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the enrollee's diagnosis does not meet the medical necessity 
for procedure code 95870 and therefore is not covered. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not substantiated their reason for denial. The procedure 
code in this case is not listed as a Group 1 code and therefore is not restricted by the diagnosis code limitations. 
Therefore, we decided that the Plan has to pay for the needle electromyography (95870) provided on July 27, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services (99213, 11604, 12032, 99000) 
provided on July 03, 2023. 
 
You asked the Plan to pay for the dermatology services (99213, 11604, 12032, 99000). You say that the 
services were medically necessary. 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 the dermatology services 
(99213, 11604, 12032, 99000) provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute treatment. 
 
You asked the Plan to pre-approve skin substitute treatment. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says it 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 skin substitute treatment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation did not describe the enrollee having failed standard 
wound treatment first prior to use of the skin substitute to meet criteria for this treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin substitute treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute treatment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the requested procedure is needed to 
treat the enrollee's chronic low back pain. The Plan denied your request. The Plan says the requested procedure 
has not been proven to treat the enrollee's condition and is not a covered service by Medicare. 
 
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 an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that based on the documentation provided, there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease (DJD) or stenosis. The enrollee's 
cause of pain is not clear; Therefore, the medical necessity criteria is not 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 an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on May 9, 2023, billed with procedure 
code 99204-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
The Plan follows Medicare rules. Medicare rules say that 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. 
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation does support the billed code. Our physician reviewer found that the record 
states that the patient was a new patient and required an evaluation and diagnosis for the complaints before 
wound care could be administered. The record supports a moderate level of medical decision making. As such, 
the record supports that 99204-25 was a significant and separately identifiable EM service. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on May 9, 2023, billed with procedure code 99204-25.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) 
provided on August 28, 2023. 
 
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 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 April 6, 2023. Therefore, 
we decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on August 21, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
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 a facility visit provided 
on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for brachytherapy services for the enrollee.

You asked the Plan to provide coverage for brachytherapy services. You say that at the time of the appeal,
these services were medically necessary. The Plan denied your request. The Plan says this treatment is
considered experimental for the enrollee's type of cancer. Maximus overturned the Plans denial for a lack of
medical records in the file. The Plan requested a reopen and provided the required medical records.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Medicare does not cover experimental services.
Based on the NCCN guidelines, brachytherapy is considered investigational or experimental for non-melanoma
skin cancers. Medicare does not cover this treatment for the enrollee's condition. Therefore, we decided that
the Plan does not have to provide coverage for brachytherapy services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 11, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be considered integral to, and therefore included in the payment for the injection service provided. Therefore, we 
decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic eye examination and the scanning laser 
provided on July 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic eye examination and the scanning laser. You say that you paid the 
$180 but you do not agree that you should be responsible for this amount. The Plan denied your request. The 
Plan says the provider was out-of-network. 
 
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 did not pre-approve the 
diagnostic eye examination and the scanning laser. We found no exception that would require the Plan to pay 
for the diagnostic eye examination and the scanning laser. Therefore, we decided that the Plan does not have to 
pay for the diagnostic eye examination and the scanning laser provided on July 20, 2023, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inqovi. 
 
You asked the Plan to pre-approve Inqovi. You say that the services are medically necessary. 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 pre-approve Inqovi.  Benefits for Inqovi 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 pay for the office visit (99214) provided on July 10, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service should be covered. 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 the office visit (99214) 
provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Volara intrapulmonary percussive ventilator 
(IPV). 
 
You asked the Plan to pre-approve IPV. You say that this helps prevent infectious, hospitalizations, or the need 
for antibiotics. The Plan denied your request. The Plan says this is not covered by Medicare for use in the 
home. 
 
The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of IPV have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a 
Volara intrapulmonary percussive ventilator (IPV).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 15, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. The rules also state that providers may bill services with a -59 modifier if the service billed with the 
modifier indicates a distinct procedural service. 
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 16 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. While modifier -59 was used for some 
of the billed units, the medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88341 billed for date of service May 15, 2023.