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

 
We decided that the Plan does not have to pay for intraoral, periapical first x-ray (D0220), intraoral, periapical 
each additional x-ray (D0230), panoramic x-rays (D0330) and bitewings (D0274) provided on August 1, 2023.  
 
You asked the Plan to pay for the dental services. You say that you asked the dental provider if the service was 
covered. You also say you were assured this was 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 intraoral, periapical first x-ray (D0220) was exhausted on date of service March 30, 
2022. The record also shows your benefit for intraoral, periapical each additional x-ray (D0230) and  bitewings 
(D0274) was met on date of service October 31, 2022. The record also shows that panoramic x-rays (D0330) 
was met on date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for 
intraoral, periapical first x-ray (D0220), intraoral, periapical each additional x-ray (D0230), panoramic x-rays 
(D0330) and bitewings (D0274) provided on August 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient admission provided from February 18, 
2023, to March 13, 2023. 
 
You asked the Plan to pay for the acute inpatient admission. You say that you would like the clinical 
information to be reviewed and the admission for acute inpatient reimbursement to be approved. The Plan 
denied your request. The Plan says there is no clinical documentation to support approval of additional days. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the documentation, there is no clinical documentation for the dates that 
were not approved. 
 
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 acute inpatient admission have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient admission provided from February 18, 2023, to March 13, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug code A2970 billed for date of 
service April 9, 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 provided 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 drug code 
A2970 billed for date of service April 9, 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97110 billed for date of service December 14, 2022. 
 
You asked the Plan to pay for procedure code 97110. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that the provided records do not support the service 
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 97110 is: Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop 
strength and endurance, range of motion and flexibility. 
 
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 procedure code 97110. Our reviewer says that procedure 
code 97110 meets criteria for payment. Our reviewer found that there is documentation to support procedure 
code 97110. The reps, exercise and/or stretches that were documented as completed support code 97110. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97110 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 97110 billed for date of service 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: Favorable

 
We decided that the Plan has to pay for procedure code 29822 rendered on June 13, 2023. 
 
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 29822 is "Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral 
bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor 
complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial 
bursa, foreign body[ies])." 
 
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 enrollee was being treated for a 
right shoulder rotator cuff tear and partial proximal biceps tendon tear. She underwent a right shoulder 
arthroscopic subacromial decompression, rotator cuff repair, and proximal biceps tenotomy on 6/13/23. The 
procedure details cite a proximal biceps tenotomy was performed. A mid-lateral working portal was established 
and the thickened bursal tissue was debrided. An anterior acromioplasty was performed. The greater tuberosity 
bone was debrided. The cuff tear was repaired. There was noted debridement of the thickened bursal tissue and 
greater tuberosity bone. Therefore, the documentation does support that CPT 29822 was rendered 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 29822 rendered on June 13, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies billed with code A0422 for date of service April 28, 2023.

You asked the Plan to pay for the ambulance supplies. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the general ambulance service and payment for them is included in the payment rate for the transport. Therefore, we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies billed with code A0422 for date of service April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive 
periodontal evaluation and diagnosis on a subsequent visit (D4355) provided on March 1, 2023. 
 
You asked the Plan to pay for the full mouth debridement. You say that you are asking to please allow your 
mom to see a reliable dentist. The Plan denied your request. The Plan says the full mouth debridement is not a 
covered expense under the enrollee's dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth 
debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit (D4355) 
provided on March 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the duplex scan of extracranial arteries 
provided by an in-network provider on April 17, 2023. 
 
You asked the Plan to waive the cost sharing for the duplex scan. You say that you do not understand why you 
are being billed. 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 $40 
copayment per provider, per date of service, for in-network routine radiology services including ultrasounds. 
 
You have been asked to pay a $40 copayment for the duplex scan. This item/service falls 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 
cost sharing for the duplex scan of extracranial arteries provided by an in-network provider on April 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neuropsychological Testing (96132, 96133, 96138, 
96139)  
 
You asked the Plan to pre-approve Neuropsychological Testing. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is not medically necessary 
if administered when the patient has a substance abuse background and any of the following apply: 
        a. the patient has ongoing substance abuse such that test results would be inaccurate, or 
        b. the patient is currently intoxicated 
 
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 Neuropsychological Testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not meet the 
criteria for psychological and neuropsychological testing as there does not appear to be a specific need for the 
testing which is asked for. It is difficult to assess you with ongoing substance use including alcohol dependence 
as you have Alcohol Induced Persisting Dementia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neuropsychological Testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Neuropsychological Testing (96132, 96133, 96138, 96139)
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 you would like an authorization to be issued immediately for the services provided. The Plan denied your request. The Plan says this request is not medically necessary.

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 have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve crown - porcelain/ceramic. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service since it not a natural tooth. 
 
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 
crown - porcelain/ceramic (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), the x-ray of the knee (73562), 
electrical stimulation (G0283) and hot or cold packs therapy (97010) provided by a chiropractor on June 12, 
2023. 
 
You asked the Plan to pay for the office visit (99213), the x-ray of the knee (73562), electrical stimulation 
(G0283) and hot or cold packs therapy (97010). You say that the visit was medically necessary. 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 (99213), the x-ray of the knee (73562), electrical stimulation 
(G0283) and hot or cold packs therapy (97010) provided by a chiropractor on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen for new information and new medical
records. This information shows the enrollees placement was requested for social issues. The hospital
discharged the enrollee home with a recommendation of home health care when the Plan denied IRF
placement. The records also do not show the enrollee required daily skilled therapy and daily skilled nursing
services in an IRF admission setting.

The Plan is correct in this case. 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. Based
on the medical records provided, the enrollee did not require daily skilled nursing and daily skilled therapy
service provided at an IRF level of care. The medical records also do not indicate the enrollee had the ability to
participate in a therapy program lasting at least three hours of therapy per day at least five days per week.
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 13, 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 overturned the Plans denial. The Plan requested a reopen and noted that per the DEX
Diagnostic Exchange Registry, code 81479 is not listed as a recommended code. Per the Medicare guidelines,
the provider did not bill with one of the recommended procedure codes for the Z-code ZB1CW.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim could
not be paid as billed due to an issue with the code billed, 81479 and the DEX Z-code billed. Medicare rules for
payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic
testing provided to the enrollee on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve denial of core buildup (D2950) and crown restorations
(D2740) for teeth #'s 25 and 26 for the enrollee.

You asked the Plan to pre-approve these dental services. You say that at the time of the appeal, these services
were medically necessary. The Plan denied your request. The Plan says this benefit was exhausted at the time
of the request. Maximus overturned the Plans denial stating the services were medically necessary. The Plan
requested a reopen and stated the issue was not medical necessity but the fact that this benefit was exhausted.

The Plan is correct in this case. 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 the Plan had previously approved 3 crown restorations and 3 core buildup services prior to this request.
Therefore, we decided that the Plan does not have to pre-approve denial of core buildup (D2950) and crown
restorations (D2740) for teeth #'s 25 and 26 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing (81599) provided on October 20, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that per the DEX Diagnostic Exchange Registry, DEX Z-Code ZBB9S
coverage status shows as "Not Covered". Based on these Medicare guidelines, the Plan correctly denied the
claim for payment as the reported Z-Code, ZBB9S, is not covered for the MoIDX program.

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 cold not be paid due to the submission of an invalid Z-Code.
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not
have to pay for genetic testing (81599) provided to the enrollee on October 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.

You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says that the step therapy
requirements have not been met. Maximus overturned the Plan's denial. The Plan requested a reopening and
stated that this medication has never been approved the Plan and is a new start. The Plan is correct in this case
as the records shows the Plan has never approved Ilumya for the enrollee.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that there is
no indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided
and the Medicare-approved major drug compendia there is no indication that the Plan's required drug(s) would
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for Ilumya.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya for the enrollee.