Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis Reader. 
 
You asked the Plan to pre-approve the Dexcom G6. The Plan denied your request. The Plan says the enrollee is 
not on insulin or does not have documentation of history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable 
and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 Mis Reader.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service March 25, 
2022. 
 You asked the Plan to pay for procedure code 88360. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 88360. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 88360. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88360 billed for date of service March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010), prefabricated abutment 
(D6056), implant supported porcelain fused to metal crown (D6066) and bone replacement graft for ridge 
preservation (D7953). 
 
You asked the Plan to pre-approve implants and associated 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 implant placement (D6010), prefabricated abutment (D6056), implant supported porcelain fused to metal 
crown (D6066) and bone replacement graft for ridge preservation (D7953).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
15, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee should not be 
responsible for the bill. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment for ambulance services.  
 
The enrollee has been asked to pay a $290 copayment for the ambulance services. This service falls within the 
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for ambulance services provided on November 
15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 1, 2022, billed with 
code 77002-XU. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is an add on code that was billed without a 
valid primary procedure.  
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, we have confirmed that code 77002 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for imaging services provided on December 1, 2022, billed with code 77002-XU.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), and 
surgical access to an implant body (D6011). 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body (D6010), and surgical access to an implant body 
(D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on May 9, 2022, to December 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that it was your understanding even if you 
went out-of-network these services would be paid. 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. 
 
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. 
 
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. Therefore, we decided that the Plan does not have to pay more for dental services provided by an out-of-
network provider on May 9, 2022, to December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95870, 95868, 95937, 95927, 95939, 
95955, and 95938 billed for date of service July 27, 2021. 
 
You asked the Plan to pay for procedure code(s) 95870, 95868, 95937, 95927, 95939, 95955, and 95938. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says these codes are included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95870, 95868, 95937, 
95927, 95939, 95955, and 95938. This means there is both a professional and technical component for the CPT 
code(s). In this case, an appropriate modifier to indicate the professional component has not been billed with 
CPT code(s) 95870, 95868, 95937, 95927, 95939, 95955, and 95938. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 95870, 95868, 95937, 95927, 95939, 95955, and 95938 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95870, 
95868, 95937, 95927, 95939, 95955, and 95938 billed for date of service July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture- mandibular (D5120). 
 
You asked the Plan to pre-approve complete denture- mandibular. 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 
complete denture- mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve the continuous glucose monitor and supplies. The Plan denied your request. 
The Plan says you do not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97035, 97140, and 97032 billed for March 
9, 2022, to April 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 97035, 97140, and 97032 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 code 97035 is application of a modality to 1 or more areas; 
ultrasound, each 15 minutes. The definition of code 97140 is manual therapy techniques (eg, mobilization/ 
manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition 
of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. 
 We find that CPT codes 97035, 97140, and 97032 are not supported in the medical record. Specifically, there is 
no documentation of at least eight minutes of therapy to meet the minimum 15 minute requirement for the 
billing of each code. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97035, 97140, 
and 97032 billed for March 9, 2022, to April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 13, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Neoplasms Gene Panel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing (NGS) is covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unspecified 
myelodysplastic syndrome. Bone marrow flow cytometry on April 14, 2023 showed myeloid blasts with 
normal immunophenotype. These myeloid blasts are of unknown significance. The documentation does not 
support that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer, and has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). The requested testing 
is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Neoplasms Gene Panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0482 for date of service 
November 23, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed 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 code G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation does not 
support that 15-22 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing billed with code G0482 for date of service November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum and bone removal (D4249) and gum surgery to 
work on teeth (D4245). 
 
You asked the Plan to pre-approve gum and bone removal and gum surgery. 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 gum 
and bone removal (D4249) and gum surgery to work on teeth (D4245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220) and prophylaxis - adult (D1110) provided on December 
14, 2022. 
 
You asked the Plan to pay more for dental services. You say that you would like the copayments waived. The 
Plan denied your request. The Plan says they are under no obligation to waive the cost share at this time. 
 
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 $15 
copayment for in-network services during the visit for covered routine dental services when provided by an in-
network provider. 
 
You have been asked to pay a total of $45 for dental services provided on December 14, 2022 ($15/visit x 3 
visits = $45). 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 pay more for periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220) and prophylaxis - adult (D1110) provided on December 
14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 3, 
2022, through December 4, 2022. 
 
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 the acute inpatient hospital care provided was 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review indicates that the enrollee presented for emergent medical attention on 
December 3, 2022. He was complaining of abdominal pain and was quickly diagnosed with a small bowel 
obstruction. The enrollee had a history of small bowel obstruction and many of these past episodes quickly 
resolved. Further, and with specific attention to this admission, the enrollee was never in hemodynamic 
jeopardy and did not have a naso-gastric tube placed. Rather, he was simply treated with supportive cares (such 
as intravenous fluids and rest). On the same day as his admission, he began to pass flatus and stool. Once again, 
as his medical history had shown multiple times in the past, the small bowel obstruction proved to be very self-
limited. The review has determined that the record did not show that at the time of the inpatient admission the 
admitting physician reasonably expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from December 3, 2022, through December 4, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 63012, 63056, 63057 rendered on June 21, 2022. 
 
You asked the Plan to pay for the services. You say that the documentation does not support the services billed. 
The Plan denied your request. The Plan says that the documentation does not support the services billed. 
 
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. The plan denied these services based on findings in the operative report. The 
operative report was not provided for review to MAXIMUS. Therefore, we decided that the Plan has to pay for 
procedure codes 63012, 63056, 63057 rendered on June 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate maxillary partial denture (D5221), 
unspecified periodontal procedure (D4999) and bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve immediate maxillary partial denture, periodontal procedure, and a bone 
replacement graft. You say that these 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 pre-approve 
immediate maxillary partial denture (D5221), unspecified periodontal procedure (D4999) and bone replacement graft for ridge preservation (D7953).