Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit, the ultrasonic guidance for 
needle placement, the dexamethasone sodium phosphate injection, and the triamcinolone acetonide injection 
provided on June 30, 2023. You asked the Plan to waive the cost sharing for the office visit, the ultrasonic guidance, and the injections. 

You say that you do not agree with the cost sharing. 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 20% 
coinsurance for Medicare Part B prescription drugs, a $20 copayment for most x-rays and ultrasounds, and a 
$35 copayment per visit to a specialist. 
 
You have been asked to pay a $0.47 coinsurance for injections ($2.37 allowed amount x .20 = $0.47). These 
items/services fall within the Medicare Part B prescription drugs benefit category. You have been asked to pay 
a $20 copayment for the ultrasonic guidance. This item/service falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. You have also been asked to pay a $35 copayment for the 
office visit. This item/service falls within the physician/practitioner services, including doctor's office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit, the ultrasonic 
guidance for needle placement, the dexamethasone sodium phosphate injection, and the triamcinolone 
acetonide injection provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (D9985) provided on July 12, 2023. 
 
You asked the Plan to pay for the sales tax. 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sales tax 
(D9985) provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided July 31, 2023, billed with 
codes 80053 81000-59, 82533, 82607, 82627-90, 82728, 82746, 82785, 83036, 83090, 83540, 83615, 83970, 
84270, 84402, 84402, 84403, 84439, 84443, 84481-59, 84550, 84436 and 84480-59, 85025 and 86038. 
 
You asked the Plan to pay for the laboratory services. You say that please find the requested documents 
attached. The Plan denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053 81000-59, 82533, 82607, 82627-90, 82728 82746, 82785, 83036, 83090, 
83540, 83615, 83970, 84270, 84402, 84402, 84403, 84439, 84443, 84481-59, 84550, 84436 and 84480-59, 
850205 and 86038 is not supported in the medical record. Specifically, the documentation did not include a 
valid physician order, lab requisition and medical records supporting the providers intent to order the tests 
billed. The records show that the Plan made multiple attempts to obtain additional information from the 
provider without success. Also, we have confirmed that codes 84481, 84439 are column two codes to column 
one codes 84436, 84480 with a modifier indicator of 0. The column two code are therefore not payable. Based 
on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided July 31, 2023, 
billed with codes 80053 81000-59, 82533, 82607, 82627-90, 82728, 82746, 82785, 83036, 83090, 83540, 
83615, 83970, 84270, 84402, 84402, 84403, 84439, 84443, 84481-59, 84550, 84436 and 84480-59, 85025 and 
86038.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on July 31, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you believe this provider should be able to be 
used with this benefit even though they are out-of-network. The Plan denied your request. The Plan says there 
is no coverage if hearing aids, or related services are received from a provider that is not part of the vender 
network. The Plan also says that the hearing benefit is not covered if the services are not registered with the 
Plan hearing in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5261) provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this power wheelchair was prescribed 
by your primary care doctor. The Plan denied your request. The Plan says the notes do not show a medical need 
to control the power options through a joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Therefore, the reviewer found that the requested upgraded electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient care billed with codes 
99233 and G8427 provided on July 8, 2023, to July 9, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the diagnosis code I46.2 was billed 
correctly, and the claim should be paid. The Plan denied your request. The Plan says the diagnosis code at issue 
is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I46.2 defined as 
cardiac arrest due to underlying cardiac condition. This code is not an appropriate primary diagnosis as the 
code has a Code first note indicating to code the underlying condition first. Based on this information, we 
decided that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital inpatient care billed with codes 99233 and G8427 provided on 
July 8, 2023, to July 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, a harness and an expandable controller. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that these power wheelchair features are covered when the 
criteria in the rules section of this letter are 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 an electronic connection between 
wheelchair controller and two or more power seating system motors, a harness and an expandable controller. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. There is not 
a medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power 
seating system motors, a harness and an expandable controller have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87486, 87498, 
87502, 87541, 87581, 87635, 87640, 87641, and 87651 for date of service June 23, 2023.  

You asked the Plan to pay for the laboratory services. 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 must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the amplified probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with codes 87486, 87498, 87502, 87541, 87581, 87635, 
87640, 87641, and 87651 for date of service June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81314, 81345, and 
81272 for May 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 
81314, 81345, and 81272 for May 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 L1 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial and failure of fracture 
bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for code D6750 or white glass with high gold
content cap for bridge for teeth 21, 28, 22 and 27 and code D6240 or false tooth for bridge for teeth 23, 24, 25
and 26.

You asked the Plan to provide coverage for the requested dental services. You say that these dental services
are medically necessary. The Plan denied your request. The Plan says the Plans dental criteria are not met.
Maximus upheld the Plans denial but described the incorrect dental service in the letter. The Plan requested a
reopen and correction of this error.

The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Your dentist requested a bridge to replace your missing teeth.

The Plans states to approve a bridge you must be missing only one upper front tooth or only two lower front
teeth. The two lower front teeth must be next to each other. You also cannot be missing any of your back teeth.
Based on the dental x-rays provided, you do not meet these criteria. Though the Plan offers a dental benefit in
excess of Medicare coverage, the dental records show the Plan's required criteria are not met. Therefore, we
decided that the Plan does not have to provide coverage for code D6750 or white glass with high gold content
cap for bridge for teeth 21, 28, 22 and 27 and code D6240 or false tooth for bridge for teeth 23, 24, 25 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness 
(E2313) and a privacy flap (K0108). 
 
You asked the Plan to pre-approve an expandable controller, expandable harness and a privacy flap. You say 
that these features are medically necessary. The Plan denied your request. The Plan says an expandable 
controller and expandable harness are not medically necessary. The privacy flap does not serve a primarily 
medical purpose. 
 
The Plan follows Medicare rules. Medicare rules say that services/items that do not serve a medical purpose are 
not covered. The rules also say that the expandable controller and expandable harness are covered when the 
criteria in the rules section of this letter are 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 an expandable controller and 
expandable harness. Our reviewer says that the expandable controller and expandable harness are not medically 
necessary. Our physician reviewer found that the provided records document that the enrollee has 3+/5 to 4+/5 
upper extremity and hand strength with no reported hand limitations, contractures, fisting, tremors, or weak 
grasp. Provided records thus indicate the enrollee has adequate upper extremity strength and function to operate 
the wheelchairs power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and expandable harness have not been met. The 
privacy flap does not serve a primarily medical purpose. Therefore, we decided that the Plan does not have to 
pre-approve an expandable controller (E2377), expandable harness (E2313) and a privacy flap (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 11, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
DEX Diagnostic Exchange Registry states procedure code 81479 is not listed as a recommended code for the
testing provided and the provider did not bill with one of the recommended procedure codes for Z-code
ZB1CW.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid code 81479 is not billable with Z-code
ZB1CW. Based on this information, we decided that Medicare rules for coverage of this testing have not been
met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on
November 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation at lumbar level L3 
and an unspecified level (22515, 22513).  

You asked the Plan to pre-approve percutaneous vertebral augmentation at lumbar level L3 and an unspecified 
level. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 percutaneous vertebral augmentation at 
lumbar level L3 and an unspecified level. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found there is no trial and failure of fracture bracing. More conservative measures are 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation at lumbar level L3 and an unspecified 
level have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
vertebral augmentation at lumbar level L3 and an unspecified level (22515, 22513).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 32 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits will help your 
current condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
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 previously been treated with outpatient therapies and should 
be independent with a home exercise program.  There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore 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 32 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve micro lighted wheels, unilateral push lock wheel lock 
right, push handles, and a transit system (K0108x4). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says micro-lighted wheels do not primarily serve a medical purpose. A wheel-
lock is requested for safety outside of the home, while you are on uneven terrain. A push handle does not 
primarily serve a medical purpose. A transit system is for use outside of the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 micro lighted wheels, unilateral push lock wheel lock right, 
push handles, and a transit system (K0108x4).