Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain has not improved 
with conservative treatment. The Plan denied your request. The Plan says the procedure has not been proven 
beneficial for the enrollee's condition.  
 
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 the requested services. Our physician 
reviewer found that the enrollee has a history of left knee pain despite arthroscopic surgery. Prior treatment 
includes medications, physical therapy, and home exercise. X-rays demonstrated moderate to severe 
osteoarthritic changes in all compartments. The request is for radio frequency ablation of the genicular nerves. 
This is considered experimental/investigational therapy.  Therefore, the request is deemed not medically 
reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the genicular nerves.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is an emergency situation that the enrollee needs 
rehabilitation and is not able to be released to go home until they can move around safely as they were prior to 
needed medical attention. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee requires the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. The enrollee was hospitalized on December 24, 2023, for atrial 
fibrillation with rapid ventricular rate, pneumonia, and a urinary tract infection with indwelling urethral 
catheter. The enrollees atrial fibrillation was likely exacerbated by pneumonia and urinary tract infections. The 
enrollee does require daily skilled nursing services, including wound management and bowel and bladder care 
as well as re-positioning for pressure wound management. The enrollee has had a decline in function and 
mobility and would benefit from physical and occupational therapies in the skilled nursing facility setting. The 
enrollee is noted to be tearful and anxious but participated in therapy with re-direction. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
  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 waive the cost share for the bitewings - four radiographic images, 
prophylaxis, intraoral - periapical first radiographic image, and the intraoral - periapical additional radiographic 
image provided on September 7, 2023. 
 
You asked the Plan to waive the cost share for the dental services represented by codes D0274, D1110, D0220,  
and D0230. You say that this was an emergency for a fractured tooth and a medical necessity. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. The Plan also says that your benefit for the 
intraoral - periapical first radiographic image (D0220) has already been exhausted. 
 
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 80% 
coinsurance for exams, cleanings and dental x-rays when provided out-of-network.  
 
You have been asked to pay 80% coinsurance for the dental services represented by codes D0274, D1110, and 
D0230. These services fall within the dental services out-of-network 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 share for the bitewings - four radiographic images (D0274), prophylaxis - adult 
(D1110), and intraoral - periapical additional radiographic image (D0230) provided on September 7, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows 
you received two of the periapical radiographic images, one on August 3, 2023, and the subsequent exam on 
September 7, 2023. Therefore, we decided that the Plan does not have to waive the cost share for intraoral - 
periapical first radiographic image (D0220) provided on September 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you cannot get around without a 
power wheelchair. The Plan denied your request. The Plan says the requested wheelchair is no appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Group 4 power wheelchairs have added capabilities that are not 
needed for use in the home. 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 pre-approve a group 4 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving the appropriate care in 
the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable for transfer and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require LTACH services that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided to the enrollee
on November 2, 2021.

You asked the Plan to pay for the Guardant Reveal testing. You say that this test was medically necessary and
was recommended in this case. The Plan denied your request. The Plan says that this test is listed in the DEX
databases as non-covered. Maximus overturned the Plan's denial based on medical necessity. The Plan
requested a reopening and stated that this is not covered by Medicare. The Plan is correct in this case.

Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment,
and approval process.

We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this
information, we decided that Medicare rules for coverage of the Guardant Reveal testing have not been met.
Therefore, we decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided to
the enrollee on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on September 28, 2023. 
 
You asked the Plan to pay for a crown (D2740). You say that you feel there should be other coverage besides 
x-rays and cleanings. The Plan denied your request. The Plan says the service is not a covered benefit under 
your 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 a crown 
(D2740) provided on September 28, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested Vabysmo is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Avastin/bevacizumab first. 
 
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 Vabysmo. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Avastin/bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212-25 provided on January 27, 2021. 
 
You asked the Plan to pay for procedure code 99212-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. 
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 97597 
provided on January 27, 2021. The documentation submitted does not support a significant, separately 
identifiable evaluation and management service to support the use of the -25 modifier Therefore, we decided 
that the Plan does not have to pay for procedure code 99212-25 provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7240). 
 
You asked the Plan to pre-approve the removal of an impacted tooth (D7240). You say that you are requesting 
that your wisdom tooth is removed as it is coming out of your gums sideways. You say you are having 
discomfort and want to be seen by an out-of-network provider to have sedation. The Plan denied your request. 
The Plan says the service is not a covered benefit regardless of if provided by an in- or out-of-network 
provider. 
 
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 removal of an impacted tooth 
(D7240) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the removal of an impacted tooth (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #9. You asked the Plan to pre-approve the surgical placement of implant body (D6010) on tooth #9. You 
say that you are appealing this denial. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
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 surgical placement of implant body 
(D6010) for tooth #9.are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the surgical placement of implant body (D6010) for tooth #9.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from August 17, 
2023, to August 18, 2023. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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, the CPT Code Manual definition of code P9016 is Red blood cells, leukocytes reduced, each unit. 
The definition of code P9059 is Fresh frozen plasma between 8-24 hours of collection, each unit. We find that 
CPT codes P9016 an P9059 were not billed as required. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital services provided from August 17, 2023, to August 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires multi-disciplinary 
approach to manage medically complex issues and this care is beyond what can be expected at an alternative 
level of care. The Plan denied your request. The Plan says the records do not show it is safe for the enrollee to 
leave the hospital, because kidney function is getting worse, blood pressures are fluctuating, and you had 
bleeding from your trach site, services are being provided in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99212) and eye refraction (92015) 
provided on June 30, 2022. 
 
You asked the Plan to pay for the outpatient office visit and eye refraction. You say that you would like these 
charges to be reduced under your health plan. The Plan denied your request. The Plan says this benefit has been 
exhausted. 
 
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 once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you already received these services on April 
28, 2022, which the Plan has paid for the claim. Based on this information, we decided that the Plan's rules for 
coverage of the outpatient office visit and eye refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient office visit (99212) and eye refraction (92015) provided on June 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 provided on October 5, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 provided on 
October 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with 
procedure code 99497. 
 
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 code. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 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 code. Our reviewer found that the medical record includes an 
evaluation for a patient with respiratory acidosis, however advanced care planning and time spent was not 
found in medical record and cannot be verified.  
 
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 April 4, 2023, billed with procedure code 
99497.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the humidifier provided on June 19, 2023. 
 
You asked the Plan to waive the coinsurance for the humidifier. You say that you did not receive this item. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the humidifier. This item/service falls within the durable 
medical equipment and related 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. The total amount you owe is $3.56 ($17.82 allowed amount x 20% = $3.56). Therefore, we decided that the Plan does not have to waive the coinsurance for the humidifier provided 
on June 19, 2023.