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

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0675) provided on 
April 19, 2023, through May 12, 2023. 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675) provided on April 19, 2023, through May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the injection services provided from 
January 28, 2021, to March 20, 2023. 
 
You asked the Plan to reduce the copayments for the injection services. You say that these services were not 
surgery. 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 $350 
copayment per date of service, for surgery services. 
 You have been asked to pay a $350 copayment for each injection service provided on January 28, 2021, 
February 20, 2023, and March 20, 2023. These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities benefit category. The total amount you owe is $1,050 ($350 
copayment x 3 injections = $1,050). 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 copayments for the injection 
services provided from January 28, 2021, to March 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service June 22, 
2023. 
 
You asked the Plan to pay for the billed service. You say that reimbursement based on the charges, time and 
work is appropriate. The Plan denied your request. The Plan says the criteria for the billed code have not been 
met. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee was 
seen for right arm pain due to a fall two week prior. The enrollee was stable with no chest pain, difficulty 
breathing, or swelling. The enrollee was treated with pain medications and instructed to see a specialist after 
discharge. The records do not show that a high level of decision making was provided. 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 code 99285 billed for date of service June 22, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323).  
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is in office to buy and bill. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of 
Orthovisc, Synvisc/Synvisc-One or Monovisc before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plan's required drug(s) would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) and to pay for 
a periodic oral evaluation (D0120), a cleaning (D1110), a resin-based composite (D2331, D2332) for tooth #23 
and #27, a complete upper denture (D5110), an interim complete upper denture (D5810), an extraction (D7210 
and D7140) for tooth #4, #6, #12, #13, #18, analgesia (D9230), an unspecified adjunctive procedure (D9999) 
provided on April 21, 2022, May 26, 2022, June 27, 2022, August 11, 2022, and October 17, 2022. You asked the Plan to pay for the dental services. You say that the claim was denied due to the timeframe, but 
you filed the claim within the 365 day timeframe. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year 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 the Plan paid $1,000 for a partial lower denture (D5214) and an unspecified adjunctive procedure 
(D9999) on August 11, 2022; therefore, your annual dental maximum benefit for the year of 2022 was 
exhausted on the date of service of August 11, 2022. Therefore, we decided that the Plan does not have to pay 
for an unspecified adjunctive procedure (D9999) and to pay for a periodic oral evaluation (D0120), a cleaning 
(D1110), a resin-based composite (D2331, D2332) for tooth #23 and #27, a complete upper denture (D5110), 
an interim complete upper denture (D5810), an extraction (D7210 and D7140) for tooth #4, #6, #12, #13, #18, 
analgesia (D9230), an unspecified adjunctive procedure (D9999) provided on April 21, 2022, May 26, 2022, 
June 27, 2022, August 11, 2022, and October 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from June 9, 2023, to July 8, 2023. 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says the enrollee did not 
require SNF care during the period in question. 
 
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 a 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 the SNF care provided from June 9, 2023, to July 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (93355-59) provided July 6, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records.  
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 93355 is a column II code to column I code 00560 however, 93355 
was billed with a modifier.  
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. After careful review of medical record and Centers for Medicare & 
Medicaid Services (CMS) guidelines, the guideline was not found to support CPT 93355 can be separately 
reported from anesthesia service CPT 00560. No modifier is allowed to bypass edit. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the echocardiography (93355-59) provided July 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from May 11, 2023, to June 9, 2023. You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says the enrollee did not 
require skilled nursing or therapy during the period in question. 
 
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 a 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 May 11, 2023, to June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761) provided on June 12, 2023. 
 
You asked the Plan to pay for the elbow orthosis. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records submitted do not indicate the enrollee needed or requested an elbow brace. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the elbow orthosis (L3761) provided on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary rehabilitation 
therapy. The Plan denied your request. The Plan says that the records show that there is no need for an 
intensive rehabilitation program.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the trips are necessary for 
you to get to your medical appointments. The Plan denied your request. The Plan says you have used up your 
benefit for the calendar year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 12 additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services as she needs 
assistance to learn to walk properly again. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for a SNF admission. 
 
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 pre-approve 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 has chronic advanced impairment and does not engage with therapy. The 
reviewer also stated daily skilled services are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on July 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you were coerced into not going to the hospital and ask for the claim to be overturned. The Plan denied your 
request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 30, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport services received on July 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport (A0428) and ground 
mileage (A0425) provided on August 10, 2023. 
 
You asked the Plan to pay for non-emergent ambulance transport (A0428) and ground mileage (A0425). You 
say that ambulance transport was required due to moderate/severe muscle weakness and deconditioned state 
precluding any significant physical activity. The Plan denied your request. The Plan says their policy covers 
non-emergency transportation when it is the only way to safety and adequately transport a member or if other 
means of transporting a member are unsafe due to a medical condition. The Plan also says that this claim does 
not meet these requirements.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergent ambulance transport (A0428) 
and ground mileage (A0425). Our reviewer says that the service was not medically necessary. Our physician 
reviewer found the enrollee was not bedbound, did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport, and transportation could have 
been provided by other means. Our physician also found that a prudent layperson would not believe that 
immediate medical attention was required for someone who was being discharged to home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent ambulance transport (A0428) and ground mileage (A0425) have 
not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport 
(A0428) and ground mileage (A0425) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown billed with code D2740 for
November 3, 2022.

You asked the Plan to pay for the dental services. You say that you were misled and should not owe for the
services. 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 Plan's coverage rules apply in this case. The Plan covers up to $1,500
every year for non-Medicare covered preventive and comprehensive dental services.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The previous
determination stated that the Plan did not provide sufficient documentation to support that you had exhausted
your $1,500 benefit limit; however, the original case file contains Explanation of Benefit (EOB) documents
showing that you had used the entire $1,500 supplemental benefit as of November 3, 2022. The record shows
that you had used $723 of your $1,5000 benefit as of November 3, 2022. The Plan applied a payment of $777
for the porcelain/ceramic crown rendered on November 3, 2022. At this time, the full $1,500 limit was met.
Further payment for these services is not covered by your supplemental benefit or Medicare benefit. Therefore,
we decided that the Plan does not have to pay for the porcelain/ceramic crown billed with code D2740 for
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180),
periapical first x-rays (D0220) and periapical each additional x-rays (D0230) provided on March 15, 2023.

You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied
your request. The Plan says that these services are not covered under the Plan's dental benefits. Maximus
partially overturned the Plan's decision. The Plan requested a reopening and stated that these services were not
covered by the Plan. The Plan is correct in this case. You did not elect the optional dental supplemental
benefits. The Plan's standard dental benefit does not cover periapical x-rays. The Plan contract also specifically
states that comprehensive periodontal exams are not a covered benefit under the standard or optional dental
benefit. 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 comprehensive periodontal evaluation (D0180), periapical first x-rays (D0220) and periapical each
additional x-rays (D0230) provided on March 15, 2023.