Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 22, 2023, with an out-of-
network provider. 
 
You asked the Plan to pay for the services provided on March 22, 2023, with an out-of-network provider. You 
say that you want the Plan to reimburse you for the services. The Plan denied your request. The Plan says based 
on a lack of information submitted, we are unable to determine that the services were considered urgent or 
emergent in nature. Services received with an out of area provider would need to be considered urgent or 
emergent to qualify for coverage or prior authorization would need to be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services provided on March 22, 
2023, with an out-of-network provider have been met. There are no medical records within the casefile. 
Without the requested clinical information, we are unable to determine if the requested services are medically 
necessary. Therefore, we decided that the Plan does not have to pay for the services provided on March 22, 
2023, with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the prophylaxis (D1110) provided on September 19, 2023. 
 
You asked the Plan to pay for the prophylaxis. You say that according to everything you could locate under 
your plan, it only states that you cannot exceed $500.00 in dental preventive care. You also say that it shows 
you have a balance of $204.00, and the summary sheet for your plan is not specific as to the quantity of 
cleanings allowed per year. The Plan denied your request. The Plan says that your benefit for the requested 
item or service has already been exhausted. 
 
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 contract states your dental benefit includes prophylaxis. The 
contract does not clearly state there is a limitation to the number of prophylaxes that are allowed per plan year. 
It is the burden of the Plan to substantiate their denial with evidence. No criteria was provided by the Plan 
showing you could have reasonably expected this service to be denied. In this case, the denial has not been 
substantiated. Therefore, we decided that the Plan has to pay for the prophylaxis (D1110) provided on 
September 19, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for any additional physical therapy visits.

You asked the Plan to provide coverage for additional physical therapy visits. You say that at the time of the
appeal, additional visits were medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus partially approved the Plans denial with one visit.

The Plan requested a reopen and stated the single visit approved for transition is not necessary and Maximus
agrees with this by stating you have an effective treatment program in place for home exercise.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy. Our physician reviewer stated skilled services are not necessary to
restore or maintain function or to prevent deterioration of your condition and the records show you have an
effective treatment program in place and will be able to continue with a home exercise program. Therefore,
continued, or additional visits do not meet medical necessity criteria. We looked at this physician's review, the
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of any
additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to
provide coverage for any additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for upgraded electronics.

You asked the Plan to provide coverage for an electronic connection, harness, and expandable controller.
The Plan denied your request. The Plan says the requested upgraded electronics are not demonstrated to be
necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not
apply the correct criteria. The Plan noted that the medical records show the enrollee has the required upper
extremity strength to operate the approved base switches.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. The available clinical documentation in the case file does not support that the
requested upgraded electronics requested were medically necessary for the enrollee in this case. The notes do
not show the medical necessity of controlling the power options through a joystick. Therefore, we decided that
the Plan does not have to provide coverage for the requested upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 6, 2023, billed with 
procedure codes 36223-XS, 36224, 36225-XS, and 36226. 
 
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 documentation does not support the billed codes. 
 
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 codes 36223-XS, 36224, 36225-XS, and 36226 is selective 
catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the 
ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes 
angiography of the extracranial carotid and cervicocerebral arch, when performed, selective catheter placement, 
internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and 
cervicocerebral arch, when performed, selective catheter placement, subclavian or innominate artery, unilateral, 
with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and 
interpretation, includes angiography of the cervicocerebral arch, when performed, and selective catheter 
placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all 
associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when 
performed. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the codes in question are not 
supported. The documentation contains a brief note listing selective catheterization, however, there is no 
detailed report supporting that these procedures were performed. 
 
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 not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 6, 2023, billed with procedure codes 
36223-XS, 36224, 36225-XS, and 36226.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 5, 2022, to 
October 13, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that G93.41 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says G93.41 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with secondary diagnosis G93.41, defined as metabolic 
encephalopathy. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that G93.41 is not supported in the documentation. 
Our physician reviewer found that medical records documented by a qualified healthcare professional do not 
include a diagnosis of G93.41 (metabolic encephalopathy) with a plan of treatment for this diagnosis, until 
discharge documentation, which does include this diagnosis. However, records do not include treatment for it 
during the hospital stay. On October 6, 2022, a case management social worker documents a diagnosis of 
G93.41, however they are not qualified to diagnose and treat this condition. In this case, there is insufficient 
and inconsistent documentation to support the diagnosis and treatment of G93.41 throughout the hospital stay, 
therefore G93.41 cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 5, 2022, to October 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT (D0365), implant placement (D6010), 
implant supported lower denture for lower arch (D6111), semi-precision abutment  placement (D6191) and 
replacement of replaceable part of semi-precision or precision attachment of implant/abutment (D6091). 
 
You asked the Plan to pre-approve these dental services. 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 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 cone 
beam CT (D0365), implant placement (D6010), implant supported lower denture for lower arch (D6111), semi-
precision abutment  placement (D6191) and replacement of replaceable part of semi-precision or precision attachment of implant/abutment (D6091).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a SPRINT peripheral nerve stimulation
(PNS) device (64555) for the enrollee.

You asked the Plan to provide coverage for a SPRINT peripheral nerve stimulation (PNS) device (64555). You
say that at the time of the appeal this device 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 and stated that Maximus did not apply the correct criteria. The Plan demonstrated that there is no local
coverage determination for Peripheral Nerve Stimulation for enrollee's state of Illinois. Per National Coverage
Determination (NCD) for Electrical Nerve Stimulators (160.7), specific coverage criteria must be met for the
approval of this type of device. The device usage information states "the SPRINT System will be left in place
for up to 60 days, after which, the MicroLead(s) will be removed by your doctor". In this case, the peripheral
nerve stimulator for the enrollee is not being used to assess suitability for permanent implants. The peripheral
nerve simulator requested is placed for up to 60 days. As the SPRINT PNS device request is not for a trial for a
permanently implanted device the Medicare coverage criteria are not met.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for this type of device. We looked at
the file and Medicare rules. Based on this information, we decided that there is insufficient information in the
record which shows the required criteria for this type of device were met at the time of the appeal. Therefore,
we decided that the Plan does not have to provide coverage for a SPRINT peripheral nerve stimulation
(PNS) device (64555) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to on April 6, 2023.

You asked the Plan to pay for these services. You say that you cannot afford this bill. The Plan denied your
request. The Plan says this testing is not covered by Medicare for this diagnosis. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered. It should also be noted the medical records contain a
document you signed on April 6, 2023, which shows you were told this may not be covered by Medicare. You
checked the box stating you wanted the test anyway and understood by signing this form you accepted financial
responsibility.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services
provided to on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), 
comprehensive series of intraoral x-rays (D0210), and periodontal scaling and root planing (D4341) provided 
on May 3, 2023, and June 5, 2023, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the dental services. You say that x-rays were needed to proceed with treatment 
and the comprehensive periodontal evaluation was necessary before the work was done so that the dentist could 
form a treatment plan. You also say that the services done on June 5, 2023, was the same treatment that you got 
on May 23, 2023, that was reimbursed, just on the other half of the mouth. The Plan denied your request. The 
Plan says the comprehensive periodontal evaluation and comprehensive series of intraoral x-rays are non-
covered services under your routine dental benefit. The Plan also says the dental services were received from 
an OON provider and are not covered by your supplemental benefits.  
 
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 comprehensive periodontal 
evaluation (D0180) and comprehensive series of intraoral x-rays (D0210) are not among those covered under 
this benefit. The record shows you received the requested dental services from an OON provider. The record 
shows that the prior authorization approval letter that was sent to you clearly stated the approval was for one 
visit for covered periodontal treatment between March 27, 2023, and May 26, 2023. The one covered visit for 
periodontal scalings and root planings (D4341) was utilized on date of service May 23, 2023, and the June 5, 
2023, date of service was outside the approval period of the prior authorization. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180), comprehensive series of intraoral x-rays (D0210), and 
periodontal scaling and root planing (D4341) provided on May 3, 2023, and June 5, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for the betamethasone acetate
injection and drug administration provided on November 4, 2022

You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.

The Plan is correct in this case. 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 20% coinsurance for Medicare Part B drugs and services. The coding issue
referenced by Maximus in the original decision does not apply in this case. 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 or reduce the cost share for the betamethasone
acetate injection and drug administration provided on November 4, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  intraoral - periapical first radiographic image (D0220) and 
intraoral - periapical each additional radiographic image (D0230) 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 February 6, 2023. 
Therefore, we decided that the Plan does not have to pay for  intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 17, 2023, to July 26, 
2023, billed with procedure code 99232. 
 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 the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F06.1. This code 
is not an appropriate primary diagnosis as the code has a code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on July 
17, 2023, to July 26, 2023, billed with procedure code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye visit provided on August 11, 2023. 
 
You asked the Plan to waive the copayment for an eye visit. You say that this was supposed to be a screening 
visit. You should not have a 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an eye visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 an eye visit provided on August 11, 2023.