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

 
We decided that the Plan does not have to pay for laboratory services billed with code 81291. 
 
You asked the Plan to pay for laboratory services billed with code 81291. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for Methylenetetrahydrofolate reductase 
is unlikely to impact therapeutic decision making in the clinical management of the patient and will be denied 
automatically as not 
medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services billed with code 81291 have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services billed with code 81291.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code Q0092 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code Q0092. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 2. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code Q0092 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q0092 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 28, 2022, billed 
with codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 28, 2022, billed with codes 81314 and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950), provided on 
February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told you maximum was $2,000. 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 an annual maximum allowance amount of $1,500 for covered dental benefits was exhausted on date of service February 9, 2023. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740), and a core build-up (D2950), provided on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor supply allowance provided on February 
8, 2023, billed with code A4239. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that this code is not payable because it has a 
status indicator of "P" in the Physician Fee Schedule, meaning it is always bundled. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's denial rationale is not correct. The status indicator would 
only refer to payment via the Physician Fee Schedule. This code was billed by a Durable Medical Equipment 
(DME) supplier and would be paid via the DME fee schedule. Per the LCD guidelines, this code is payable 
when the CGM is covered up to one every 30 days. There was no evidence that the CGM is not covered by the 
Plan, nor that this was billed less than 30 days from prior deliveries of supplies. Therefore, we decided that the 
Plan has to pay for the continuous glucose monitor supply allowance provided on February 8, 2023, billed with 
code A4239.  
 
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 comprehensive oral evaluation (D0150) provided on 
December 15, 2022. 
 
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 on date of service March 2, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on December 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 4, 2022, to October 3, 2022.

You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.

The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. 

We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from September 4, 2022, to October 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95941 and 95938 billed for date of service 
January 21, 2022. 
 
You asked the Plan to pay for procedure code 95941. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95941 and 95938 billed for date of service January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-rays, an amalgam, 
cleaning, and filling (D0120, D1110, D2394, D2150, D0274) provided from February 8, 2021, to February 28, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and you were not aware of your coverage. The Plan denied your request. The Plan says the 
services denied correctly as the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until April 18, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation, bitewing x-rays, an amalgam, cleaning, and filling 
(D0120, D1110, D2394, D2150, D0274) provided from February 8, 2021, to February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 17, 2023, billed 
with procedure codes 74240, 74230, 72040, 70100 and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
which includes the administration of a substance to the patient. Therefore, we decided that the Plan does not 
have to pay for radiological services provided on January 17, 2023, billed with procedure codes 74240, 74230, 
72040, 70100 and 70310.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a SNF stay provided from January 1, 2023, 
to January 30, 2023. 
 
You asked the Plan to reduce the copayment for a SNF stay. You say that you believe the copayment for the 
SNF stay is too high. 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 $0 
copayment for days 1 to 20 and a $196 copayment for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $3,382 for a SNF stay. This total is less than the standard copayment for a SNF 
stay because the Plan applied the 2022 EOC SNF benefit coverage of $178 copayment per day for days 21 to 
100 ($178 per day x 19 days = $3,382). This item/service falls within the SNF care 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 reduce the copayment for a SNF stay provided from January 1, 2023, to January 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 18, 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 $1,000 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 dental services provided on January 18, 2023.
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 you feel the LTACH admission is necessary due to your medical history, and you are not able to afford rehabilitation. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH. Maximus overturned the Plan's denial. The Plan requested a reopening and sent in medical records for review.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a LTACH services. Our Medical Director states that the documentation does not support that you required services at the LTACH that were not available at the acute care hospital where you were receiving care. There were no required medical services identified that were available at the LTACH, that were not available at the health care setting offered by the health plan. The documentation does not support that the requested LTACH services were medically necessary and reasonable for the diagnosis and condition of you at the time. Our Medical Director found that your condition does not meet Medicare criteria for LTACH services.

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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5828, L5845 L5848, and L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the requested microprocessor knee is 
medically necessary.  The Plan denied your request. The Plan says that the enrollee does not meet criteria for a 
microprocessor knee. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 microprocessor knee. Our reviewer 
says that the enrollee meets criteria for a microprocessor knee. Our physician reviewer found the Plan appears 
to be attempting to impose stricter documentary criteria to access standard K3 care than Medicare would allow, 
and on the other hand this enrollee (as a bilateral amputee) is not even strictly bound by K-levels, so his care 
requests should be given wider latitude. There is no mention of assistive devices, and their use is not, per se, 
disqualifying of K3-status in the LCD. 
 
The LCD also states, A fluid, pneumatic, or electronic/microprocessor knee...is covered for beneficiaries 
whose functional level is 3 or above.  No further specific documentation is required in the LCD, the Policy 
Article, or any of the relevant Medicare manuals because Medicares policy recognizes that microprocessor 
knees are the basic standard of care for all above knee amputee community ambulators given that the evidence 
of their benefits and superiority to alternative knees are so well proven and long standing. 
 
The medical record here sufficiently documents his K3-level and specific need for a microprocessor knee for 
greater safety and stability. But, beyond that, the LCD suggests that this case is not even bound by the 
enrollees K-level, when it says, It is recognized, within the functional classification hierarchy, that bilateral 
amputees often cannot be strictly bound by functional level classifications.  As such Medicare would grant 
even greater deference to the recommendations of this enrollees treating clinicians and their very standard 
request. 
 
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 microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee (L5828, L5845 L5848, and L5856).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria, and acellular Pertussis vaccine. 
 
You asked the Plan to pay for Tetanus, Diphtheria, and acellular Pertussis vaccine. You say that it is medically 
necessary. The Plan denied your request. The Plan says the tetanus vaccination is not covered under your health 
Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria, 
and acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria, and acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay for 
Tetanus, Diphtheria, and acellular Pertussis vaccine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 9, 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 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 dental services provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341) for 2 
quadrants provided by an out-of-network provider on December 13, 2022. 
  You asked the Plan to pay more for the dental services. You say that you do not understand why the claim was 
denied and it was the same thing that the Plan paid for in January. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.  
 
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. 
 
For each periodontal scaling and root planing the total amount billed for each service was $248 and the total 
allowed amount for each service was $143 leaving a difference of $105 ($248 billed - $143 allowed). The 
difference for both dental services was $210 ($105 difference + $105 difference). You have been asked to pay 
the difference between the out-of-network providers charges and the Plans payment. 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 pay more for the periodontal scaling and root planing (D4341) for 2 quadrants provided by an 
out-of-network provider on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the partial upper denture (D5213) and the partial lower 
denture (D5214) provided on November 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the dentures would not 
be billed until 2023. The Plan denied your request. The Plan says your annual dental benefit for the year has 
already been exhausted. Also, it was verified that you received the dentures on November 9, 2022. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $136 for dental services on February 16, 2022. On May 18, 2022, the Plan paid $297 for 
dental services. On September 20, 2022, the Plan paid $140 for dental services. On October 6, 2022, the Plan 
paid $755 for dental services. On November 9, 2022, the Plan paid $672 for dental services. For the year of 
2022 the Plan paid $2,000 ($136 paid + $297 paid + $140 paid + $755 paid + $672 paid) for dental services. 
Therefore, your annual dental benefit for the year of 2022 was exhausted on the date of service of November 9, 
2022. Therefore, we decided that the Plan does not have to pay more for the partial upper denture (D5213) and 
the partial lower denture (D5214) provided on November 9, 2022.  
 
Your complaint about when the provider said they would bill for the dentures is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.