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

 
We decided that the Plan does not have to pre-approve an office visit for observation (D9430). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 an 
office visit for observation (D9430).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are medically 
necessary. The Plan denied your request. The Plan says you do not meet the criteria for the remaining 4 
additional PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have been receiving physical therapy. It is noted that you have 
been experiencing increased pain and difficulty performing daily activities. The documentation is unclear if 
you are making objective progress with range of motion and motor strength. If you are not making progress 
with 24 PT visits, you should be re-assessed to determine the etiology and treatment of your shoulder pain. 
Therefore, the 8 additional PT visits 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted
that this enrollee's ability to participate in intensive therapy was described as limited by the hospital physical
therapist, given their current level of function, maximum assistance of two people for bed mobility and
standing. The enrollee was also unable to perform transfer or gait training due to increased pain level with
weight bearing. Medicare coverage criteria were not met.

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. Based on the medical records provided,
the enrollee was not expected to be able to participate in at least three hours of therapy per day at least five
days per week. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to
provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions (D0431). 
 
You asked the Plan to pre-approve adjunctive pre-diagnostic test that aids in detection of mucosal 
abnormalities including premalignant and malignant lesions (D0431). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this service is not covered under your benefit. 
 
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 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions (D0431).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services for procedure code 43236 for date 
of service February 14, 2023. 
 
You asked the Plan to pay for assistant surgeon services for procedure code 43236. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. 

In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 43236. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
assistant surgeon services for procedure code 43236 have not been met. Therefore, we decided that the Plan 
does not have to pay for assistant surgeon services for procedure code 43236 for date of service February 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that this is not cosmetic dentistry. You also 
say the broken tooth is painful and causes pain to the gum. The Plan denied your request. The Plan says core 
buildup is not a covered expense. 
 
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 core 
buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 25, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are asking to please see the enclosed 
information in regard to your right to request the plan to vacate the dismissal of appeal request as the enclosed 
information shows the requested information was received by the date requested. 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 provided 
on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit option, and backrest option 8 degree with 
push handles. 
 
You asked the Plan to pre-approve the transit option and backrest option 8 degree with push handles. You say 
that a K4 or lower cannot accommodate the necessary wheel camber and placement that the enrollee requires. 
The Plan denied your request. The Plan says these items do not meet the Medicare criteria for durable medical 
equipment and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the transit option, and backrest option 8 degree with push 
handles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraorifice barrier (D3911). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 an 
intraorifice barrier (D3911).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF services to be provided by an OON provider.  
 
You asked the Plan to pre-approve the SNF services. You say that you would receive better care at this facility. 
The Plan denied your request. The Plan says there are network providers that can provide these services. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the SNF services to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rabeprazole Sodium.

You asked the Plan to pre-approve the medication. You say that this medication is medically necessary for the enrollee's treatment of gastroesophageal Reflux Disease (GERD). The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rabeprazole Sodium.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 23, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
23, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 23, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 23, 2023, as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 23, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 
2023, forward.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on June 2, 2023, to June 9, 2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records indicate the 
enrollee required inpatient hospital services that could not have been provided at a lower level of service. The 
Plan denied your request. The Plan says that they have only approved coverage for the inpatient stay provided 
until June 1, 2023, because the enrollee's coverage termed. 
 
The Plan must follow Medicare rules. Medicare rules say that if coverage under an MA plan ends while the 
beneficiary is an inpatient in a hospital facility, that MA plan is responsible for the inpatient services until the 
date of the beneficiary's discharge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have been met. Therefore, we decided that the Plan has to pay for 
inpatient hospital services provided on June 2, 2023, to June 9, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 18, 2023, to May 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to use your $1,000 benefit 
toward your dental work. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your plan paid $818 for date of service May 18, 2023, and $182 for date of service May 18, 2023 ($818 
+ $182 = $1,000). Therefore, your $1,000 annual maximum has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the dental services provided on January 18, 2023, to May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214, 62368, and J1170 provided on 
March 14, 2023, and March 21, 2023. 
 
You asked the Plan to pay for procedure codes 99214, 62368, and J1170. You say that the medical records 
support the billing of codes 99214, 62368, and J1170. The Plan denied your request. The Plan says the medical 
records do not support the billing of codes 99214, 62368, and J1170. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. The definition of code 62368 is Electronic analysis of 
programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir 
status, alarm status, drug prescription status); with reprogramming. The definition of code J1170 is Injection, 
hydromorphone, up to 4 mg. 
 
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 procedure codes 99214, 62368, and J1170. Our reviewer says 
that the medical records do not support the billing of codes 99214, 62368, and J1170. Our reviewer found the 
documentation from March 14, 2023, described the enrollee was there for a pain pump refill. However, the 
documented note does not describe the enrollee receiving an injection of hydromorphone (up to 4 mg) as this 
drug was not specifically mentioned nor the amount being less than or equal to 4 mg to support the billing of 
code J1170. Also, the documentation from March 21, 2023, described the enrollee presenting for another pain 
pump refill. She reported her chronic pain but no other complaint. The pump required re-anchoring due to the 
enrollee losing then gaining weight. No medication dose or type was adjusted, and the enrollee was stable. 
Although the note from this date supported an appropriate history and examination, the code, 99214 was not 
supported for this date due to the documentation not supporting a moderate level of decision making. Also, 
code 62368 was not supported in the documentation from this date as there was no record of electronic analysis 
of the pump being performed. 
 
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 codes 99214, 62368, and J1170 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99214, 62368, and J1170 provided on March 
14, 2023, and March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G2023, U0003, and U0005 billed for date of 
service February 23, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not payable. 
 
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 G2023 is specimen collection for severe acute respiratory 
syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source. We find that code 
G2023 is not supported. The documentation provided does not show that the enrollee was home bound.  
 
We find that U0003, billed with the QW modifier is not supported. Code U0003 is not a waived test. This 
means that the QW modifier was not correctly billed.  
 
In this case, we have confirmed that code U0005 is an add-on code. Because the primary procedure code, 
U0003, is not payable in this case, the add-on code is also not payable.  
 
We looked at the file and the rules. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes G2023, U0003, and U0005 billed for date of service February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6060 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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 pre-approve 
abutment supported crowns (D6060 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on April 10, 2023.

You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 Plan's 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 dental services provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on April 4, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services 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 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this code is a not otherwise 
specified code, and the documentation does not contain a complete description of the not otherwise specified 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 provided on 
April 4, 2023.