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

We decided the Plan does not have to pay for codes 20680 and 27335 billed to the enrollee for December 13,
2022.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria for code 20680. The Plan notes that code 20680-59-RT, a
deep removal of implant (buried wire, pin, screw, metal band, nail, rod or plate) is documented in the operative
note submitted for review; however, this procedure is considered inclusive to CPT code 27447-RT, a condyle
and plateau arthroplasty of the knee, medial and lateral compartments with or without patella resurfacing (total
knee arthroplasty). The hardware removal was needed to perform the total knee replacement at the same
anatomic site. Per NCCI Policy Manual Chapter IV- G (Fractures, Dislocations, and casting, Splinting,
Strapping, 10), CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod) are not
separately reportable if the removal is performed as a necessary integral component of another procedure.

Similarly, if a superficial or deep implant requires surgical removal, it is not separately reportable if it is
performed as an integral part of another procedure. The proper criteria for approval of a Modifier to bypass the
NCCI PTP edit has not been met. The documentation to validate the modifier must support a different session,
different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or
separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day
by the same individual. In this case, the records do not support these required billing criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that providers may bill
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The
medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Specifically, the documents received do not support that the procedure or service was distinct or
independent from other services performed; therefore, the requested modifier is not supported. Based on this
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been
met. Therefore, we decided that the Plan does not have to pay for codes 20680 and 27335 billed to the enrollee
for December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950 x2) and a pontic (D6245) provided on 
June 12, 2023. 
 
You asked the Plan to pay for core buildup and a pontic. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 pay for core 
buildup (D2950 x2) and a pontic (D6245) provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional power wheelchair accessories
(E2310) for the enrollee.

You asked the Plan to provide coverage for additional power wheelchair accessories (E2310). The Plan denied
your request. The Plan says the Medicare coverage criteria for these accessories are 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 as the enrollee shows in the medical records to have 5/5 strength in the
right upper extremity, the enrollee has more than adequate strength to operate the standard switches that come
with the approved chair and does not require the upgraded joystick.

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. Based on the medical records provided the
documentation does not support that the requested upgraded electronics were medically reasonable and
necessary for the enrollee in this case. The notes do not show the medical necessity of controlling the power
options through a joystick.

Medicare rules for coverage of the upgraded electronics are not met. Therefore, we decided that the Plan does
not have to provide coverage for additional power wheelchair accessories (E2310) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on November 9, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that that the claim has been submitted and ask 
for the payment to be reprocessed. The Plan denied your request. The Plan says the corrected claim was not 
received within one year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until June 7, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral evaluation, problem focused (D0160) provided on July 
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 January 18, 2023, and 
July 26, 2023. Therefore, we decided that the Plan does not have to pay for oral evaluation, problem focused (D0160) provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (99203) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a consultation to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership purchased on July 27, 
2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the gym membership is not 
payable as it was purchased from an out-of-network provider. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the gym membership in this case was 
purchased from an out-of-network provider. Specifically, the Plans contract states that supplemental coverage 
is provided for a gym membership only when purchased from the Plans select fitness provider. Therefore, we 
decided that the Plan does not have to issue reimbursement for the gym membership purchased on July 27, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that 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 care 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 noted that the documentation submitted by the provider indicates the enrollee has
non-operable pubic rami fractures with well controlled chronic medical problems including constipation, type
II non-insulin dependent diabetes, hypothyroidism and OSA.

The medical records do not show the enrollee was expected to be able to participate in a therapy program to
include 3 hours a day for 5 days a week in an IRF level of care.

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, at the time of the appeal, the enrollee did not meet the required criteria nor did
the enrollee require the level of care provided in an IRF admission. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that you want the 
denial overturned in order to give you a better quality of life. The Plan denied your request. The Plan says the 
Vertiflex procedure is not medically necessary. The Plan says the placement of the Vertiflex at L4-L5 will not 
address the disease at the other spinal levels. 
 
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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertiflex device is experimental for use in spine surgery. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 23, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you want a refund of the full $150. 
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 $50.00 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50.00 copayment for an office 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 office visit provided on November 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that you are appealing the 
denial. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services provided on May 15, 2023. 
 
You asked the Plan to pay for vision care services. You say that there were no authorizations or referrals given, 
the patient just came in. 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 vision care services 
provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an out-of-network eye visit and diagnostic testing 
provided on May 2, 2023. 
 
You asked the Plan to waive the cost for an eye appointment and tests. You say that no one consulted or 
explained the costs of these services. 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, and a 50% coinsurance for vision care.  
 
You have been asked to pay a combined total of $119.58 ($17.80 + $61.78 + $40 = $119.58) for an eye 
appointment and tests.  This item/service falls within the vision care 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 for an 
out-of-network eye visit and diagnostic testing provided on May 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on June 26, 2023. 
 
You asked the Plan to pay for mental health services. You say that this was medically necessary please review 
and issue payment. 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 mental health services 
provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four crowns (D2740) provided on February 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work because you were 
in pain. The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service February 13, 2023. Therefore, 
we decided that the Plan does not have to pay for four crowns (D2740) provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313) and
expandable controller (E2377) for the enrollee.

You asked the Plan to pre-approve an electronic connection, harness and expandable controller. You say that
these items are medically necessary. The Plan denied your request. The Plan says that the items are not
medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, harness and expandable controller. Our Medical Director states that the enrollee has a history of
traumatic spinal cord injury and paraplegia. It is documented that she has bilateral 3/5 motor strength in her
elbows, wrists, and hands. The documentation supports that the enrollee's upper extremity strength is adequate
to control the power options using their own switches. Our Medical Director found that the enrollee's condition
does not meet criteria for coverage of an electronic connection, harness and expandable controller.

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 electronic connection, harness and expandable controller have not been met.
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness
(E2313) and expandable controller (E2377) for the enrollee.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99283) provided on August 
19, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (99283) 
provided on August 19, 2023.