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

 
We decided that the Plan does not have to pay for the dental services (D4266, D7953, and D7510) on July 20, 
2023. 
 
You asked the Plan to pay for the dental services (D4266, D7953, and D7510). You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D4266, D7953, and D7510) on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown, porcelain/ceramic (D2740) provided on July 19, 
2023. 
 
You asked the Plan to pay for 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 pay for crown, porcelain/ceramic (D2740) provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is a medical necessity. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for this service. 
 
The Plan follows Medicare rules. The 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 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 CGM. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found the record indicates that you have diabetes. The 
record does not indicate that you are being treated with insulin or have problematic hypoglycemia as defined by 
Medicare rules. The elements of coverage criteria are not satisfied. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Remicade. 
 You asked the Plan to pre-approve Remicade. You say that you would have to pay $1,500 for Inflectra which 
you cannot afford. The Plan denied your request. The Plan says the Plan requires a trial of Inflectra before it 
will approve Remicade. 
 
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 Remicade. Our reviewer says that you 
do not meet criteria for a step therapy exception for Remicade. Our physician reviewer found you have not 
tried and failed the Plan's preferred drug of Inflectra. The record does not show that this drug would likely be 
less effective and/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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Remicade.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not receiving the care needed at their 
current location and requires therapy services to return to their normal functional status. The Plan denied your 
request. The Plan says the enrollee's records do not show that they require ongoing daily skilled therapies or 
daily skilled nursing care. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve bilateral radiofrequency ablation. You say that this is medically necessary. 
The Plan denied your request. The Plan says this does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint denervation (also called 
Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bilateral radiofrequency ablation have not been met. Specifically, radiofrequency ablation of the 
sacroiliac joint is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
bilateral radiofrequency ablation of the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS cytopathology and histopathology testing (88361,
88312, 88112, 88305) provided to the enrollee on October 4, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. The Plan denied
your request. The Plan says there were no medical records submitted to show this testing was medically
necessary as opposed to being a screening. Maximus overturned the Plans denial for insufficient records in the
file. The Plan requested a reopen and stated that as an out of network provider, the Plan has no control over the
records submitted and lab results and an order to not qualify as proof of medical necessity.

The Plan is correct in this case. 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.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of this testing have been met. Therefore,
we decided that the Plan does not have to pay for the WATS cytopathology and histopathology testing (88361,
88312, 88112, 88305) provided to the enrollee on October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Given there are offered alternatives, 
LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 1, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was for emergency transport. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R19.7 has an Excludes1 note in relation to R10.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), intraoral 
- periapical each additional radiographic image (D0230), and periodontal scaling and root planing - four or 
more teeth per quadrant (D4341) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the plan provided you with this provider so you 
would like the plan to reconsider the denial. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by your supplemental benefits.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images 
(D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), and periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat ESI. 
 
You asked the Plan to pre-approve repeat ESI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 repeat ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the cervical epidural steroid injection 
performed on 08/25/2023 provided 80-90% pain relief for a period of one (1) week. The review has determined 
that the enrollee does not meet the LCD criteria for coverage. The repeat C5-C6 ESI is not medically 
reasonable or 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service January 31, 2023. 
 
You asked the Plan to pay for procedure code 99223. 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 procedure code 99223. Our reviewer says that the documentation does not support the code billed. Our reviewer found the enrollee was evaluated by 
Infectious Disease, after being hospitalized with pneumonia. Standard treatment recommendations were made 
and are not considered to represent medical decision making of high-complexity. The amount of time spent 
caring for the enrollee is not documented. Therefore, code 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 07, 2023. 
 
You asked the Plan to pay for lab testing. You say that the results help treat the enrollees. 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 testing provided on 
June 07, 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 this enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 the medical record overall significantly complies with the various documentation 
requirements for an IRF admission, as best summarized by the physician's appeal letter from October 27, 2023. 
The enrollee's condition is sufficiently complex, and there is every reason to expect that they will participate in 
and benefit from IRF-level services to include at minimum, physical and occupational therapy, physician 
oversight of polypharmacy and re-bleeding risk, and case manager coordination of any additional services that 
might be needed to make a sustainable return home, as well as avoid preventable readmissions to the acute 
hospital. Therefore, the requested inpatient rehabilitation facility admission is approved.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollee's condition is complex and fragile, and there is adequate reason to expect that they will 
participate in and benefit from IRF-level services to include at minimum physical and occupational therapy, 
physician oversight of polypharmacy, and case manager coordination of any additional services that might be 
needed to make a safe return home versus exploring other more sustainable residential options for them as well 
as to avoid preventable readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation 
facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 73610-TC-59-LT billed for 
date of service April 25, 2023. 
 
You asked the Plan to pay for 73610-TC-59-LT. You say that 73610-TC-59-LT should be paid as billed 
because it is supported in the medical record and the correct place of service was billed. The Plan denied your 
request. The Plan says 73610-TC-59-LT is denied because payment for this service was included in the 
payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. We confirmed that code 73610 is a radiology procedure which has both a TC and a professional component (PC). We confirmed that in this case, the enrollee was a hospital 
outpatient on the date of service, April 25, 2023. The TC of a radiology service which has both a TC and PC 
cannot be paid to the provider who ordered the radiology service when the enrollee receives this service while 
outpatient at a hospital. Based on this information, we decided that Medicare rules for coverage of 73610-TC-
59-LT have not been met. Therefore, we decided that the Plan does not have to pay for the radiology services 
coded as 73610-TC-59-LT billed for date of service April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 pay for a crown (D2740) provided on April 27, 2023.