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

 
We decided that the Plan does not have to pre-approve an EW-72 four-wheeled scooter. 
 
You asked the Plan to pre-approve an EW-72 four-wheeled scooter. You say that you have been homebound, 
and it is very difficult for you to make it to appointments, grocery shopping, the pharmacy, and more. You also 
say that you are on oxygen and have to carry your tanks and machine when you leave your home. The Plan 
denied your request. The Plan says the request for the purchase of an EW-72 four-wheeled scooter is not 
medically necessary and is not approved at this time. The Plan also says the requested EW-72 four-wheeled 
scooter is listed as a recreational scooter with added capabilities which is not needed for home use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an EW-72 four-wheeled scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #6, the pontic (D6245) 
for tooth #7, and the retainer crown (D6740) for tooth #6 and #8 provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have $6,000 in coverage for dental and your 
coverage should include simple extractions. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the core buildup, the pontic, and the retainer crown 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #6, the pontic (D6245) for tooth #7, and the retainer crown (D6740) for tooth #6 and 
#8 provided on August 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the SNF stay provided from August 4, 
2023, to August 26, 2023. 
 
You asked the Plan to reduce the copayment for the SNF stay. You say that you were told that you would not 
have a copayment for the first 20 days. 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 $0 
copayment per day, for days 1 to 20 and a $196 copayment per day, for days 21 to 100 for each skilled nursing 
facility benefit period. 
 
The record shows you had two previous skilled nursing facility stays within the benefit period of this service. 
You have been asked to pay a $196 copayment per day, for 22 days of the SNF stay. You have been asked to 
pay a total of $4,312 ($196 copayment x 22 days = $4,312). This item/service falls within the skilled nursing 
facility 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 reduce the copayment for the SNF stay provided 
from August 4, 2023, to August 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services performed on May 10, 2023.  
 
You asked the Plan to pay for the outpatient hospital services. You say that the outpatient hopsital services 
should be paid as billed because they are supported in the documentation. The Plan denied your request. The 
Plan says the outpatient hospital services are denied due to I/OCE edits 62, 40, and 15. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. The rules also say that no separate payment is ever made for codes with a status 
indicator of B on the Physician Fee Schedule. The rules also say that Column One/Column Two Correct 
Coding and Mutually Exclusive Edits are code pairs that should not be reported together or should not be 
reported together without an appropriate modifier. The rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. 
 
We looked at the file and Medicare rules. 90999 was denied due to I/OCE edit 62, which indicates that the code in question is not recognized by OPPS. We confirmed that in this case procedure code 90999 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code 90999 is not separately payable, 
therefore the denial of 90999 is appropriate. 84132, 80047, and 85014 were denied due to I/OCE edit 40, which 
indicates that payment for the code in question is bundled because it is a column 2 code to a column 1 code 
billed on the same claim. In this case, we confirmed that 84132 is a column 2 code to column 1 code 80047 
billed on the same claim. Code 80047 is a column 2 code to column 1 code 80053 billed on the same claim. 
Code 85014 is a column 2 code to column 1 code 85025 billed on the same claim. This claim has not been 
billed with the appropriate modifiers to bypass the edit, therefore the denials of 84132, 80047, and 85014 are 
appropriate. 94660 was denied due to I/OCE edit 15, which indicates the maximum allowable units of per day 
of a code have been exceeded. In this case, we confirmed that code 94660 has an MUE of 1 and an MAI of 2. 
You billed 2 units of this code, exceeding the maximum allowed per day. Therefore, the denial of 94660 is also 
appropriate. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital 
services performed on May 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided September 1, 2023, 
through September 5, 2023. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the denial of payment 
on this claim. The Plan denied your request. The Plan says the claim form does not have the appropriate home 
health data to process and pay claim. The claim must have the appropriate type of bill to process. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed 
with an invalid type of bill. We find the Medicare rule for payment of this September 1, 2023, through 
September 5, 2023, claim has not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided September 1, 2023, through September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of a nasal valve collapse with low energy 
(30469), an excision or destruction, intranasal lesion (30117) and an ablation, soft tissue of inferior turbinates 
(30801). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that you are requesting reconsideration and 
submitted medical records for review. The Plan denied your request. The Plan says there is insufficient 
literature to support the safety and efficacy of radiofrequency treatment of nasal valves for the treatment of 
nasal airway obstruction. 
 
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 VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal congestion secondary to nasal 
obstruction from a deviated septum and hypertrophic inferior turbinates. There is insufficient literature to 
support the safety and efficacy of the requested service for the enrollee's specific conditions. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied.  The requested service is not 
recommended. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of a nasal valve collapse with low energy (30469), an excision or 
destruction, intranasal lesion (30117) and an ablation, soft tissue of inferior turbinates (30801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit on April 11, 2023 provided on April 11, 2023. 
 
You asked the Plan to pay for an office visit on April 11, 2023. You say that the service at issue was a medical 
necessity for the enrollee. 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 on April 
11, 2023 provided on April 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from June 30, 2023, to July 29, 2023. 
 
You asked the Plan to pay for SNF care. You say that the SNF services were medically necessary and covered. 
The Plan denied your request. The Plan says the enrollee did not require daily skilled nursing or therapy 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from June 30, 2023, to July 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that that the enrollee has suffered from 
chronic intractable low back pain for quite some time and despite utilizing gabapentin and tramadol, as well as 
facet joint injections their pain remains unrelenting. The Plan denied your request. The Plan says the sprint 
PNS system is not medically necessary. 
 
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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is considered experimental for pain and more research is needed. 
 
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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 16, 2023, to 
April 14, 2023. 
 
You asked the Plan to pay for the home health services billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date as required. Based on this information, we 
find that the Medicare rules for payment of the claim at issue have not been met. Specifically, the final home 
health claim was not billed with the correct admission date of February 15, 2023. The NOA is required to 
match the same date as billed on the claim. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from March 16, 2023, to April 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services provided on August 26, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON services. You say that the facility is responsible for obtaining the 
authorization. The Plan denied your request. The Plan says the services were not urgent or emergent. 
 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that 
the Plan does not have to pay for the monitoring services provided on August 26, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service February 22, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the testing 
exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
records provided do not show how the results of testing will impact clinical management in a manner already 
demonstrated in the peer-reviewed published literature. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
(D7210), topical application of fluoride varnish (D1206), gingival irrigation with a medicinal agent  per 
quadrant (D4921), and periodontal maintenance (D4910) provided on June 28, 2023, and July 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration stating you 
paid $139 out-of-pocket for the tooth removal and the dentist charged $334 for removal of bone without your 
approval. The Plan denied your request. The Plan says your benefit for the requested services $2,000 dollar 
limit was met. 
 
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. Specifically, 
the benefit for supplemental covered is limited to $2,000 annually. The records show the Plan paid $402 under 
claim number ending in 37978 for dental services provided on April 6, 2023. The records show the Plan paid 
$402 under claim number ending in 43635 for dental services provided on April12, 2023. The records show the 
Plan paid $898 under claim number ending in 25028 for dental services provided on May 16, 2023. The 
records show the Plan paid $298 under claim number ending in 27984 for dental services provided on June 6, 
2023. This means that the Plan paid $2,000 in total for dental services provided in 2023. This exhausted the 
annual dental benefit allowance for the 2023 calendar year. Therefore, we decided that the Plan does not have 
to pay for the extraction, erupted tooth requiring removal of bone (D7210), topical application of fluoride 
varnish (D1206), gingival irrigation with a medicinal agent  per quadrant (D4921), and periodontal 
maintenance (D4910) provided on June 28, 2023, and July 5, 2023.  
 
Your complaint about the amount the dentist charged you for services is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023, to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 should be paid as billed because 
there are not any contracted providers in the enrollee's geographical area to perform this service. The Plan 
denied your request. The Plan says the billed code is invalid 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023, to September 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the testing services. You say that the testing should be covered. The Plan denied 
your request. The Plan says no authorization has been obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the lab testing provided on June 8, 2023, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on July 24, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the COVID-19 testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on July 24, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the reconstruction of the maxilla/mandible with
implants, a bone graft, and a maxillofacial oral appliance for the enrollee.

You asked the Plan to provide coverage for the reconstruction of the maxilla/mandible with implants, a bone
graft, and a maxillofacial oral appliance for the enrollee. You say that at the time of the appeal, these dental
services were medically necessary. The Plan denied your request. The Plan says the requested dental services
are not a covered benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract criteria.

The Plan is correct in this case. 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.
Review of the Plans dental contract does not show coverage is provided for the requested services.

Therefore, we decided that the Plan does not have to provide coverage for the reconstruction of the
maxilla/mandible with implants, a bone graft, and a maxillofacial oral appliance for the enrollee.