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

 
We decided that the Plan does not have to pay for the dental services on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laminectomy (63046) provided on December 12, 2022. 
 
You asked the Plan to pay for the laminectomy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 code 63046 is not supported in the medical record. Specifically, the records show this 
procedure was performed in the outpatient setting, however the claim was billed with an inpatient place of 
service (21). Based on this information, we decided that Medicare rules for coverage of the laminectomy have 
not been met. Therefore, we decided that the Plan does not have to pay for a laminectomy (63046) provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) 
and the custom fabricated abutmentincludes placement (D6057) provided on January 5, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your supplemental 
dental policy. 
 
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 items provided are not among those 
covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown 
(D6058) and the custom fabricated abutmentincludes placement (D6057) provided on January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 18, 2022 to August 
16, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. The rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the current code that describes the services performed 
 
In this case, the home health claim was not billed with a required "G" code to reflect the service that most of 
the visit was spent on. Without this required code reported, billing requirements have not been met. Therefore, 
we decided that the Plan does not have to pay for home health services provided on July 18, 2022 to August 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99221) provided on November 27, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code cannot be paid. 
 
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 99221 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient. 
 
We find that CPT code 99221 is not supported in the medical record. Specifically, this code was already paid 
for this date of service. Based on this information, we decided that Medicare rules for coverage of initial 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital 
care (99221) provided on November 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization procedure (36247, 
36248, 37243, 76937). 
 
You asked the Plan to pre-approve the genicular artery embolization procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says this procedure is investigational and non-
covered. 
 
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 genicular artery embolization 
procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found while the studies are noted to be promising, further research is 
needed to show that geniculate artery embolization is as good as or better than standard treatments for knee osteoarthritis. 
 
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 genicular artery embolization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular artery embolization procedure (36247, 36248, 
37243, 76937).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 87426, U0005 and U0003 
provided October 7, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the records provided support the medical 
necessity of the service in dispute. The Plan denied your request. The Plan says the claim was received after the 
timely filing limitation. 
 
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 laboratory service was not filed until January 27, 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 the laboratory service coded as 87426, U0005 and U0003 
provided October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interoperative monitoring (G0453) provided October 20, 
2022 
 
You asked the Plan to pay for the interoperative monitoring. You say that this service was medically necessary. 
The Plan denied your request. The Plan says insufficient records were provided to support the number of units 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 19 units of CPT code G0453 are not supported in the medical record. Insufficient records were 
submitted to support multiple units. The plan requested additional records and none were provided. Based on 
this information, we decided that Medicare rules for coverage of the interoperative monitoring have not been met. Therefore, we decided that the Plan does not have to pay for interoperative monitoring (G0453) provided 
October 20, 2022
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 21, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient 
rehabilitation services require prior authorization. 
 
We looked at the file and Medicare rules. The physical therapy services at issue were not authorized. Based on 
this information, we decided that Medicare rules for coverage of physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on November 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nuclear imaging of hepatobiliary system (78226) provided 
on December 23, 2022. 
 
You asked the Plan to pay for the hepatobiliary system imaging. You say that the correct place of service was 
billed. The Plan denied your request. The Plan says the incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the Place of Service (POS) 
code assigned by the physician/practitioner for the professional component (PC) of a diagnostic service shall be 
the setting in which the enrollee received the technical component (TC) service. 
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient POS code must be used. Based on this information, we decided that Medicare rules 
for coverage of the hepatobiliary system imaging have not been met. Therefore, we decided that the Plan does 
not have to pay for a nuclear imaging of hepatobiliary system (78226) provided on December 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic sleeve gastrectomy (LSG). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy is covered when 
the beneficiary has a body-mass index (BMI) of 35 kg/m2 or higher. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the most recent provided records document the enrollee's BMI as 34.27 mg/m2. The criteria for 
coverage is not met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laparoscopic sleeve gastrectomy (LSG).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided on January 23, 2023. We also decided that the Plan does not have to 
pay for an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth  and including 
elevation of mucoperiosteal flap if indicated (D7210) provided on January 23, 2022. 
 You asked the Plan to pay more for the extraction, erupted tooth or exposed root (D7140). You also asked the 
Plan to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth  and including 
elevation of mucoperiosteal flap if indicated (D7210). You say that you feel the Plan should cover all seven 
teeth as an extraction at $109.00. 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. The Plan also says D7210 is not on the list of covered benefits under this plan and is therefore your 
liability. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the extraction, erupted tooth or exposed root (D7140). 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 an extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on 
January 23, 2023. We also decided that the Plan does not have to pay for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth  and including elevation of mucoperiosteal flap if indicated (D7210) 
provided on January 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has no been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the continuous glucose monitor have been met. No medical records were provided to support this request. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power recline seating system back, expandable 
controller with related electronic assembly and harness, power seat elevation feature, SD card, side shroud, and 
controller shroud request for repair. 
 
You asked the Plan to pre-approve the repair items listed above. You say that this should be approved as 
requested. The Plan denied your request. The Plan says these items cannot be covered as criteria for them are 
not met.  
The Plan follows Medicare rules. Medicare rules say that coverage for power wheelchair features is allowed 
when reasonable and necessary according to the criteria in the Medicare rules section of this letter. 
 
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 repair items listed above. Our 
reviewer says that the documentation does not support the medical necessity of the power tilt seating or 
expandable controller. Our physician reviewer found the enrollee has a venous insufficiency ulcer on her calf. 
She has relied on a wheelchair for some time and has no other skin issues. She does not use a catheter. She 
does not have spasticity and has normal strength in her hands. As such, she does not meet criteria for the power 
tilt seating system. Additionally, she has adequate arm strength and range of motion to use the power switches 
for power seating actuators. It is not medically necessary for these to be controlled from the main drive control. 
 
The requested power seat elevator is noncovered by Medicare. The SD card, side shroud, and controller shroud 
are not considered primarily medical in nature and cannot be covered as durable medical equipment.  
 
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 repair items listed above have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power recline seating system back, expandable controller with related 
electronic assembly and harness, power seat elevation feature, SD card, side shroud, and controller shroud 
request for repair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of brain without 
contrast material (70551) provided on December 27, 2022. 
 
You asked the Plan to pay for the MRI. You say that the correct place of service was billed. The Plan denied 
your request. The Plan says the incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the Place of Service (POS) 
code assigned by the physician/practitioner for the professional component (PC) of a diagnostic service shall be 
the setting in which the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient POS code must be used. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for a 
magnetic resonance imaging (MRI) of brain without contrast material (70551) provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 6, 2018, to May 22, 2018. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on February 6, 2018, to May 22, 2018.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections for two spinal levels. 
 
You asked the Plan to pre-approve the two-level facet joint injection. You say that you are trying to get two 
codes approved instead of the three initially requested. The Plan denied your request. The Plan says that the 
denial was forwarded to Maximus for review as the Plan did not make a determination within the required time 
frame. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the 
criteria listed in the Medicare 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 the two-level facet joint injection. Our 
reviewer says that the requested injections at two levels are medically reasonable and necessary. Our physician 
reviewer found the Provided records document moderate to severe chronic neck pain, predominantly axial, that 
causes functional deficit measured on pain or disability scale; pain present for minimum of 3 months with 
documented failure to respond to noninvasive conservative management (as tolerated); absence of untreated 
radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) and 
there is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patients pain, including but not limited to fracture, tumor, infection, or significant deformity. All criteria for 
the requested services are met. 
 
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 two-level facet joint injection have been met. Therefore, we decided that the 
Plan has to pre-approve facet joint injections for two spinal levels.  
 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.