Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing 1-3 teeth (D4342), core 
buildups (D2950), crown tooth #15 (D2790) and drug and/or medicaments by report (D9630). 
 
You asked the Plan to pre-approve these dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for a crown (D2790) and core buildup (D2950) have not been 
met. The Plan also says periodontal scaling and root planing is not medically necessary and drug and/or 
medicaments by report 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 Plan's coverage rules apply in this case. The Plan covers these dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found core buildup is not necessary on 
tooth #8 and #9 as there is enough remaining tooth structure to retain a crown on these teeth. The x-ray for 
tooth #15 does not show a fracture and more information is needed to determine if a crown and core buildup 
would be necessary for this tooth. In addition, scaling and root planing is not necessary as there was no 
periodontal chart record included or bitewing radiographs that show clinical attachment loss. 
. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve periodontal scaling and root planing (D4342), core buildup (D2950), crowns for 
tooth #8 and #9 (D2740), crown for tooth #15 (D2790) and drug and/or medicaments by report (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
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 will not require more than 25 days to be weaned off oxygen. The 
requested services are not medically necessary as the enrollee is currently receiving adequate care at the health 
care facility being provided by the health Plan.  
 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D2950). 
 
You asked the Plan to pre-approve the dental service (D2950). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the dental service D2950 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental service (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150 x4) for teeth 
#'s 18, 19, 30 and 31 by an endodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation (D0150 x4) for teeth #'s 18, 19, 30 and 31 
by an endodontist. You say that you need a total of four extractions and were only approved for three. You say 
you need this approved with all the pain you are experiencing. The Plan denied your request. The Plan says 
consults provided by endodontists, other dental specialists or non-network general dentists are not covered. 

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 pre-approve a 
comprehensive oral evaluation (D0150 x4) for teeth #'s 18, 19, 30 and 31 by an endodontist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342-26-59 billed for date of service June 
27, 2023.  
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 4 units of this 
code. The documentation shows that the Plan paid for 2 units of code 88342. The documentation does not show 
that 2 additional units were provided. Based on this information, we decided that Medicare rules for coverage 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88342-26-59 billed 
for date of service June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81479, 81235, 81275, 81404, and 81405 
billed for date of service July 24, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the coding is not supported. 
 
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.  
 
The file shows that a CNSide test was provided. We looked at the file and Medicare rules. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
81479, 81235, 81275, 81404, and 81405 billed for date of service July 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. 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. 
 
The Plan follows Medicare rules. Medicare rules say that effective April 7, 2022, the Centers for Medicare & 
Medicaid Services (CMS) covers Food and Drug Administration (FDA) approved monoclonal antibodies 
directed against amyloid for the treatment of AD when furnished in accordance with Section B under coverage 
with evidence development (CED) for patients who have a clinical diagnosis of mild cognitive impairment 
(MCI) due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent 
with AD. 
 
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 Leqembi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provider documents on October 11, 
2023 that overall, this is more likely depression than dementia. She however is convinced that there is dementia 
present. The enrollee's Montreal Cognitive Assessment score improved from 18/30 on July 22, 2022 to 24/30 on January 7, 2023 and then 22/30 on November 4, 2023 without any treatment. The provider references a prior 
magnetic resonance imaging (MRI) and a history of prior cerebral vascular accident (CVA), however there is 
no formal MRI of the brain provided that has been completed in the past year. There is no documentation of 
apolipoprotein E (ApoE) genotype testing and no documentation of a formal discussion the provider had with 
the enrollee informing the risk for amyloid-related imaging abnormalities (ARIAs). The review has determined 
that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code A9270. 
 
You asked the Plan to pre-approve procedure code A9270. You say that the item is necessary. The Plan denied 
your request. The Plan says the billed code is not covered for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9270 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code A9270 is not covered for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code A9270 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve procedure code A9270.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), harness for upgrade to 
expandable controller (E2313), occupied transit (K0108), and ModEvoOrange joystick (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, harness, occupied transit, 
and ModEvoOrange joystick. You say that the services are necessary. The Plan denied your request. The Plan 
says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 an electronic connection, expandable 
controller, harness, occupied transit, and ModEvoOrange joystick. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found provided records document that the enrollee has 4/5 bilateral upper extremity strength and is independent 
with feeding thus indicating he has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. Provided records document no medical need for the other accessories. 
 
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, expandable controller, harness, occupied transit, and 
ModEvoOrange joystick have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
expandable controller (E2377), harness for upgrade to expandable controller (E2313), occupied transit 
(K0108), and ModEvoOrange joystick (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
May 30, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that surgery was medically 
necessary. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 and 20936 has a status indicator of B on the Physician Fee Schedule. This 
means that the codes are not separately payable. 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 pay for procedure codes 
20930 and 20936 billed for date of service May 30, 2023.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 12, 2023.

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. 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 the ambulance services provided on September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low air loss mattress. 
 
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 a Group 2 support surface 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 criteria for coverage are not met. Our physician reviewer found that the records show that the enrollee has 
muscular dystrophy and intact skin. The criteria for coverage are not met and the services are therefore not 
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 low air loss mattress.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for SelectMDx testing provided to the enrollee on January 17, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the technical assessment for this type of testing was not available for coverage at the
time of service. Maximus overturned the Plans denial. The Plan requested a reopen and noted that review of the
MolDX program website (https://app.dexzcodes.com/app#!catalogDetailPage) show the technical assessment
for SelectMDx was not effective until February 17, 2023.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, it has been confirmed the services billed to the enrollee were not
available for coverage at the time of service. Based on this information, we decided that Medicare rules for
payment of these services have not been met. Therefore, we decided that the Plan does not have to pay for
SelectMDx testing provided to the enrollee on January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services (64635, 64636) at 5
levels for the enrollee.

You asked the Plan to pre-approve radiofrequency ablation services. You say that the requested services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says that the request is not medically
necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for radiofrequency
ablation services. Our Medical Director states that the enrollee has spondylolisthesis, bulging disc and facet
arthropathy at L5-S1 with mild central canal stenosis, and foraminal stenosis on the right, as well as bulging
disc with progressive facet arthropathy and thickening of the ligamentum flavum at L4-5 with mild central
spinal stenosis demonstrated on magnetic resonance imaging (MRI) on January 20, 2023. The Plan is correct in
this case. Approval for five level of RFA on the lumbar spine was requested. Per LCD L33930, "One to two
levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of
medical necessity on appeal. A session is a time period, which includes all procedures (i.e., MBB, IA, facet
cyst ruptures, and RFA ablations) that are performed during the same day." Our Medical Director found that
the enrollee's condition does not meet criteria for coverage of radiofrequency ablation services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that
the Plan does not have to pre-approve radiofrequency ablation services (64635, 64636) at 5 levels for the
enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PrismRA test (81479) provided to the enrollee on June
12, 2023.

You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan
denied your request. The Plan says the requested test does not meet requirement for approval.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for the PrismRA test.
Our Medical Director states that there is insufficient clinical evidence in the available medical literature at this
time supporting that PrismRA testing is medically reasonable and necessary for patients with rheumatoid
arthritis. Available clinical studies do not provide sufficient information regarding the impact of PrismRA
testing on patient outcomes. In addition, no clinical guidelines currently recommend PrismRA testing for
informing treatment selection in patients with RA. Our Medical Director found that the enrollee's condition
does not meet criteria for coverage of the PrismRA test.

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 PrismRA test have not been met. Therefore, we decided that the Plan does
not have to pay for the PrismRA test (81479) provided to the enrollee on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for allergen immunotherapy (95117) provided on November 2, 2022.

You asked the Plan to pay for these services. You say that the Plan should pay this claim. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and noted that per the 2022 National Physician Fee Schedule Relative Value File
October Release: Procedure code 95117 has a PCTC indicator of 5. Per Medicare Claims Processing Manual
Chapter 23, Section 50.6 - Physician Fee Schedule Payment Policy Indicator File Record Layout, Professional
Component (PC)/Technical Component (TC) Indicator: PCTC indicator 5 - Payment may not be made by
carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient
department. Modifiers 26 and TC cannot be used with these codes. Per Medicare Claims Processing Manual
Chapter 26, Section 10.5 - Place of Service Codes (POS) and Definitions: Place of Service 26 is defined as a
Military Treatment Facility. As the claim was billed with Place of service 26, which would be considered a
hospital outpatient department, and procedure code 95117 has a PCTC indicator of 5, payment may not be
made by carriers for these services.

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 codes. In this case, this claim
could not be paid due to an error with the POS code reported. Based on this information, we decided that
Medicare rules for payment of these services have not been met. Therefore, we decided that the Plan does not
have to pay for to pay for allergen immunotherapy (95117) provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor kit.  
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have recurrent problematic hypoglycemia. 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 Freestyle Libre 3 sensor kit.