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

 
We decided that the Plan does not have to pay for imaging services provided on September 19, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 70450-26-77 is Computed tomography, head or brain; 
without contrast material. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical records provided do not 
include sufficient documentation to validate that a computed tomography, head or brain; without contrast material was performed, therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D2950) on November 21, 2022. 
 
You asked the Plan to pay for the dental service (D2950). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the dental service (D2950) 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D2950) on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite - one surface, posterior 
(D2391), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), periodic oral evaluation - 
established patient (D0120), intraoral - periapical first radiographic image (D0220), and intraoral - periapical 
each additional radiographic image (D0230) provided on December 28, 2022. 
 You asked the Plan to pay more for the dental services represented by codes D2391, D1110, D0274, D0120, 
D0220 and D0230. You say that you had routine yearly x-rays and they were not covered. You also say that 
very little of your filling was covered. 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 your benefit for the intraoral - periapical each additional radiographic image 
D0230 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 intraoral - periapical each additional radiographic image D0230 was exhausted on 
the same date of service. The claim paid correctly on the appealed claim. 
 
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 a resin-based composite - one surface, 
posterior (D2391), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), periodic oral 
evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), and intraoral - 
periapical each additional radiographic image (D0230) provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this is medically necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 63053) rendered on December 14, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
code 63053 is "Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody 
arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary 
procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite an L3 
laminectomy with facetectomy, foraminotomy, and decompressing the L3 nerve roots was performed using a 
combination of high-speed bur, curettes, Kerrisons, Penfield dissectors, nerve blocks, and pituitary rongeur. 
This was above and beyond the necessity for interbody fusion. Similarly, L4 decompression, decompressing 
the L4 nerve roots was performed in a similar fashion. Therefore, the records do support that CPT 63053 was 
rendered in this case? 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 63053) rendered on December 14, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you live alone and cannot navigate up and down your stairs after your surgery. The Plan denied your request. The Plan says that the request is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services. 

The MAXIMUS Physician Reviewer determined that the complexity of the enrollee's nursing, medical, and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The Plan requested a reopen and argues that the Maximus reviewer did not consider your ability to participate in intensive therapy was described as limited by the hospital therapist, due to increased pain and dizziness limiting ability to participate in therapy. 

The medical records show you have a medical history that included hypertension, obesity, sleep apnea, GERD, and hepatitis. The enrollee underwent bilateral knee replacement surgery on October 26, 2022. At the time of the review, the records show you were in significant pain. You required moderate assistance for bed mobility, contact guard assistance for transfers and minimum assistance for lower body dressing. You were ambulating 25 feet with a walker with contact guard assistance. Sleep apnea was stable. Blood pressure was normal. On October 27, 2022, it is noted that you were doing very well with physical therapy. On October 28, 2022, you complained of bilateral knee pain, and stated you thought you worked too much with therapy the day prior. 

The Plan is correct in this case. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. At the time of the appeal, you said that skilled nursing facility services are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus upheld the Plans denial. The Plan requested a reopen and asked Maximus to clarify the service requested was skilled nursing facility services and not inpatient rehabilitation services.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 cover SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's nursing, medical and rehabilitation needs does not require an inpatient SNF level of care. The enrollee was admitted for altered mental status, bacteremia and hypotension. Medical problems are stable. There are no complex nursing or rehabilitation needs. The records do not show the enrollee requires daily skilled nursing or skilled therapy treatment on an inpatient basis. Any further treatment can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the extracorporeal shockwave treatments (0101T x 11) provided from 
October 19, 2022, through November 23, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not payable as they are 
considered experimental. 
 
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. Specifically, the Plan has stated that the services at issue are not payable as they 
are not a covered benefit. However, the Plans contract provides coverage for therapies as a supplemental 
chiropractic benefit. The Plan does not clearly disclose what therapies are covered under this benefit. 
Additionally, the Plan reviewed a call made by you to customer service asking about covered services and you 
were told that for the shockwave treatment, as long as meeting Medicare guidelines it would fall under the $25 
copayment.  The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pay for the extracorporeal shockwave treatments (0101T x 11) provided from 
October 19, 2022, through November 23, 2022.  
 
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 procedure code 99053 billed for date of service November 
12, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the patient was seen twice on this date of 
service. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not 
separately payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 12, 2022.
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 the hospital is unable to provide the care 
you need. The Plan denied your request. The Plan says the enrollee records do not meet all the requirements 
needed; services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that you require that are not available at 
the current health care setting being offered by the health plan. 
 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you felt as 
if you were having a stroke. You also say that you are asking the denial to be reconsidered. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 27, 2022. 
 
You asked the Plan to pay for the dental service. You say that you never used your dental insurance in 2022 
and you should not have to pay for your cleaning. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of September 28, 
2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent (D4921) 
provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan did not pay their share of this claim. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan and the 
cost sharing was charged correctly. 
 
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. Additionally, the out-of-network cost sharing was charged correctly. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent 
(D4921) and any additional cost sharing for the dental services provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the deluxe frame eyeglasses (V2025) and lens (V2100) provided on 
December 15, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the vision items. You say that the prescribed eyeglasses were medically 
necessary. The Plan denied your request. The Plan says that that the vision items are not covered when received 
by an out-of-network provider. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC) for the 
appealed date of service. Without the correct EOC we are unable to determine if the claim was processed 
correctly. Therefore, we decided that the Plan has to pay for the deluxe frame eyeglasses (V2025) and lens 
(V2100) provided on December 15, 2022, by an out-of-network provider.  
 
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 periodontal maintenance (D4910) provided on November 1, 
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. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on November 1, 2022.