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

We decided that the Plan does not have to pay for the lab testing services (81479) provided to the enrollee on November 2, 2021.
You asked the Plan to pay for the lab testing services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the Z-code provided is not covered. Maximus overturned the Plan's denial. The Plan noted that per the DEX Diagnostic Exchange Registry, the DEX Z-Code Z00D0 coverage status shows as "Not Covered" for Medicare billing. The Plan included the registry page that confirms this.
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 the reported DEX-Z code is not covered for Medicare claims. Therefore, we decided that the Plan does not have to pay for the lab testing services (81479) provided to the enrollee on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a right 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
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 pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee has right shoulder 
pain with plans for an approved right shoulder arthroplasty procedure. This is a request for inpatient services 
related to this elective, non-emergent procedure. However, based on the provided documentation, the enrollee 
does not have an unstable condition or high-risk factors to expect that she would require hospital services that 
would likely cross two midnights following this typically ambulatory procedure.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acute inpatient hospital admission for a right shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36222-50, 76937-TC-59, and Q9967 
rendered on April 21, 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 the denied codes are not supported. 
 
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 the denied codes is: 
 
CPT code 36222: Selective catheter placement, common carotid or innominate artery, unilateral, any approach, 
with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision 
and interpretation, includes angiography of the cervicocerebral arch, when performed  
CPT code 76937: Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access 
sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
CPT code Q9967: Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 
 
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 not supported by the medical records. Our reviewer found that the provided records do not 
document selective catheter placement, common carotid or innominate artery, unilateral, any approach, with 
angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and 
interpretation was performed on the right side. Records do not specify selected vessel patency or permanent 
recording and reporting. Provided records do not confirm that the National Drug Code (NDC) number 
submitted on the medical claim form matches the drug documented. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36222-50, 76937-TC-59, and Q9967 rendered on April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that the service 
was approved so the cost should be covered by the Plan. 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 $220 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $220 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam restoration (D2140) for tooth #5 provided on 
June 9, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the amalgam 
restoration is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
amalgam restoration (D2140) for tooth #5 provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adult prophylaxis (D1110) and a comprehensive oral 
evaluation (D0150) 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
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 July 17, 2023. Therefore, 
we decided that the Plan does not have to pre-approve an adult prophylaxis (D1110) and a comprehensive oral 
evaluation (D0150)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 24, 2023. 
 
You asked the Plan to pay for the medication. You say that you were unaware that you would be charged for 
medication provided in the emergency room. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on April 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77525) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve proton beam therapy 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 
proton beam therapy (77525) 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 pre-approve a porcelain/ceramic crown (D2740) for tooth number 9. 
 
You asked the Plan to pre-approve the dental services. You say that you had a root canal/crown on this tooth 
last year. You also say that now there is an infection under the crown, so it needs to be done again. 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 October 19, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth 
number 9.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that you feel you are not doing well and need 
additional therapy. The Plan denied your request. The Plan says the requested services are not medically 
reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested physical therapy is generally accepted as a specific and 
effective therapy for knee pain after total knee arthroplasty. You have had 40 sessions of physical therapy and 
are currently performing a home exercise program and dynamic stretching and strengthening exercises. You are 
noted to have continued limited range of motion and function, but your progress with continued therapy has not 
significantly changed in terms of range of motion. You are performing a home exercise program. While 
physical therapy is indicated after total knee arthroplasty, you have received well over the typical number of 
physical therapy visits and your range of motion has not significantly changed with ongoing physical therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine 
(72040), and the x-ray exam of the thoracic spine (72070) provided on May 10, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine (72040), and the 
x-ray exam of the thoracic spine (72070) provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic pontic (D6245). 
 
You asked the Plan to pre-approve porcelain/ceramic pontic (D6245). You say that the enrollee experiences 
difficulties eating and always end up with food under the partial, which is uncomfortable and inconvenient. 
You also say the partial is chronically loose and is frequently dealing with mouth sores. The Plan denied your 
request. The Plan says the service provided is not covered based on corporate medical policy criteria. 
 
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 
porcelain/ceramic pontic (D6245).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 15, 2022. 
 You asked the Plan to pay for the lab services. You say that the services were provided independently of the 
hospice care. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010), electrical stimulation 
(97032), and the neuromuscular reeducation (97112) provided on April 17, 2023 and May 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the hot or cold packs therapy (97010), electrical stimulation (97032), and 
the neuromuscular reeducation (97112) provided on April 17, 2023 and May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewings (D0273) and the panoramic radiographic 
image (D0330) and to pay for the limited oral evaluation (D0140) and the intraoral radiographic images 
(D0220 and D0230) provided by an out-of-network provider on March 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the dentist was out-of-
network and you are appealing the dental services. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Also, the limited oral evaluation and the intraoral radiographic images are not 
covered by the Plan. 
 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. 
 
The total amount billed for the bitewings (D0273) was $78 and the total allowed amount was $31 leaving a 
difference of $47 ($78 billed - $31 allowed). The total amount billed for the panoramic radiographic image 
(D0330) was $176 and the total allowed amount was $88 leaving a difference of $88 ($176 billed - $88 
allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
limited oral evaluation and the intraoral radiographic images are not covered under the Plans dental benefit. 
Therefore, we decided that the Plan does not have to pay more for the bitewings (D0273) and the panoramic 
radiographic image (D0330) and to pay for the limited oral evaluation (D0140) and the intraoral radiographic 
images (D0220 and D0230) provided by an out-of-network provider on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on May 
3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that you would owe nothing. 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 D0330 was exhausted on date of service December 27, 2021 with the approval of D0210. Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) 
provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation (D9222 and D9223) and the therapeutic 
parenteral drugs (D9612) provided on June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the office never told you that the dental services 
would not be a covered benefit. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the deep sedation and the therapeutic parenteral drugs are not covered by the Plan. 
 
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 the deep 
sedation (D9222 and D9223) and the therapeutic parenteral drugs (D9612) provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be paid. 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 2, 2023, and 
April 4, 2023. Therefore, we decided that the Plan does not have to pay for an oral exam provided on May 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower tooth supported overdenture (D5865) and surgical 
placement of mini implant (D6013). 
 
You asked the Plan to pre-approve 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 27, 2023. 
Therefore, we decided that the Plan does not have to pre-approve lower tooth supported overdenture (D5865) and surgical placement of mini implant (D6013).