Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a CT scan of the chest for the enrollee.

You asked the Plan to provide coverage for a CT scan of the chest. The Plan denied your request. The Plan says
the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria and the incorrect imaging was ordered by the
provider.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a CT scan of the
chest. The Maximus Physician Reviewer determined that the service is medically necessary. The Plan
requested a reopen and stated although the intended test was computed tomography angiography (CTA), the
request for a CT scan of the chest ordered in error by the providers office. The Plan is correct in this case. The
documentation provided does not support that a CT scan of the chest is medically reasonable and necessary for
this enrollee. It is clear that the CT scan was ordered in error. We looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the
chest have not been met. Therefore, we decided that the Plan does not have to provide coverage for a CT scan
of the chest for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build-ups (D2950), retainer crowns (D6740), and 
pontics (D6245), provided on August 8, 2023 
 
You asked the Plan to pay for the dental services. You say that this dental work should be covered. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service August 8, 2023. Therefore, we 
decided that the Plan does not have to pay for core build-ups (D2950), retainer crowns (D6740), and pontics 
(D6245), provided on August 8, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your upper denture broke, and your dentist 
requested approval for new dentures but the Plan denied them. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because dentures 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) for tooth #7 and a retainer crown (D6740) 
for tooth #6, #8, and #9 provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not know why the Plan is not paying the 
amount the dentist is charging. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the pontic and a 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 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 a pontic 
(D6245) for tooth #7 and a retainer crown (D6740) for tooth #6, #8, and #9 provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), a 2D 
radiographic image (D0340), a diagnostic cast (D0470), a cleaning (D1110), an unspecified maxillofacial 
prosthesis (D5999), and an unspecified procedure (D9999) provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are sending the bill with the appropriate 
billing codes and the device should be covered under your durable medical equipment benefit. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct because dental services are 
not covered by the Plan. Also, it was verified there was no contact with the Plan prior to the date of service to 
verify the cost share for the dental services. The provider should submit code E0486 for coverage under your 
medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The requested periodic oral evaluation, bitewings, a 2D radiographic image, a diagnostic cast, a cleaning, an 
unspecified maxillofacial prosthesis, and an unspecified procedure in dispute meets the Medicare definition of 
dental, since it is a service which involved the care and treatment of teeth or structures directly supporting the 
teeth. The periodic oral evaluation, bitewings, a 2D radiographic image, a diagnostic cast, a cleaning, an 
unspecified maxillofacial prosthesis, and an unspecified procedure do not fall under any of Medicare 
exceptions for coverage of non-routine dental care. These are dental services that are not covered or paid for by 
Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), 
bitewings (D0274), a 2D radiographic image (D0340), a diagnostic cast (D0470), a cleaning (D1110), an 
unspecified maxillofacial prosthesis (D5999), and an unspecified procedure (D9999) provided on September 6, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that this is medically necessary as other 
conservative treatment has not worked. The Plan denied your request. The Plan says this is not reasonable or 
medically necessary because it is experimental. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is not clear. There is no magnetic resonance imaging (MRI) 
showing only Modic changes without facet degenerative joint disease or stenosis. .We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on July 13, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this vaccine is not an eligible Part B immunization 
unless directly related to the treatment of an injury or direct exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on July 
13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87651, 87640, and 87798 
billed for date of service May 18, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87651, 87640, and 87798. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment 
for codes 87481, 87653, 87651, 87640, and 87798 are bundled into payment for code 87801. 
 
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 codes 
87481, 87653, 87651, 87640, and 87798 are column II codes to column I code 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit as the records do not support modifier 59. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87481, 87653, 87651, 87640, and 87798 billed for date of service May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the upper partial denture (D5213) and 
the lower partial denture (D5214) provided on June 12, 2023. 
 
You asked the Plan to issue additional payment for the dental items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the dental items provided 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 dental items provided was exhausted on date of service June 12, 2023.  
  
 
Specifically, the Plans contract states that the annual maximum dental benefit is $1,500. The Plan previously 
issued payments in the amount of $1,500 ($1,123.20 + $326 + $50.80) for the dental items/services provided 
this calendar year. Therefore, you have exhausted the allowable benefit for the dental items provided in this 
case. Therefore, we decided that the Plan does not have to issue additional payment for the upper partial 
denture (D5213) and the lower partial denture (D5214) provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on July 18, 2023. 
  
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the dental service 
provided 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 benefit for the dental service provided was exhausted on date of service July 18, 2023. Specifically, 
the Plan's annual maximum allowable dental benefit is $1,500. The Plan previously issued payment to the 
provider in the amount of $1,500 for dental services provided on this day. Therefore, you have exhausted the 
allowable benefit for the dental service at issue. Therefore, we decided that the Plan does not have to pay for 
core buildup, including any pins when required (D2950) provided on July 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty surgery.  
You asked the Plan to pre-approve kyphoplasty surgery. You say that the enrollee has not had the fracture for 
more than 12 weeks so you hope this will be the best option. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty surgery. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding the onset of pain to corroborate that this compression fracture is acute or subacute. Additionally, 
there is no documentation of a progression of the body height loss, kyphotic deformity, or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion and other 
plausible causes of pain. Therefore, the enrollee does not meet the indications for this procedure and does meet 
contraindications for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Asceniv. 
 You asked the Plan to pre-approve Asceniv. You say that the use of Asceniv is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried or shown intolerance to any of the preferred drugs 
over the requested drug in Asceniv. 
 
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 Asceniv. Our reviewer says that the 
enrollee does not meet the criteria for the requested drug. Our physician reviewer found in this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation indicating that the Plan's 
required drug(s) would likely be less effective and/or likely 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 Asceniv have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the use of Asceniv.  
 
Benefits for Asceniv may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 4, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images, core buildup services, 
3D Dental surface scan, and additional intraoral x-rays (D0350, D0230, D2950, D0801) provided on June 30, 
2023, to July 11, 2023. 
 
You asked the Plan to pay for 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 your benefit for intraoral x-rays has already been 
exhausted. Coverage for the 2D oral/facial photographic images, core buildup services, and 3D Dental surface 
scans 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 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 intraoral x-rays was exhausted on the appealed claim with date of service June 30, 2023 
(D0230).  Moreover, this benefit does not include 2D oral/facial photographic images, core buildup services, or 
3D Dental surface scans. Therefore, we decided that the Plan does not have to pay for 2D oral/facial 
photographic images, core buildup services, 3D Dental surface scan, and additional intraoral x-rays (D0350, 
D0230, D2950, D0801) provided on June 30, 2023, to July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bicep tendon repair, distal claviculectomy, shoulder 
arthroscopy with debridement and shoulder arthroscopy with decompression. 
 
You asked the Plan to pre-approve these medical services. You say that you have a torn bicep tendon that needs 
surgery. The Plan denied your request. The Plan says other causes of pain have not been ruled out and there is 
no documentation of a three-month trial of doctor ordered treatment that has not helped. 
 
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 these medical services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the surgery 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 these medical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the bicep tendon repair, distal claviculectomy, shoulder arthroscopy with 
debridement and shoulder arthroscopy with decompression.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) provided on August 22, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental item provided is not a covered 
benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated 
post and core in addition to a crown (D2954) provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does show the enrollee 
requires ventilatory support and tolerated and was treated with bilevel positive airway pressure (BIPAP) with 
average volume-assured pressure support (AVAPS) with improvement of symptoms and laboratory data. The 
enrollee did not fail BIPAP therapy and hence tolerated the therapy enough to be discharged from 
hospital. Hence, there is no indication for a home ventilator given data and documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).