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

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (D7140) and 
panoramic radiographic image (D0330) provided on August 18, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 an 
extraction, erupted tooth or exposed root (D7140) and panoramic radiographic image (D0330) provided on August 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure. It is the subject of ongoing clinical 
trials. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia, anxiolysis (D9230) and 
bone replacement graft for ridge preservation (D7953) provided on August 21, 2023. 
 
You asked the Plan to pay for these dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 inhalation 
of nitrous oxide/analgesia, anxiolysis (D9230) and bone replacement graft for ridge preservation (D7953) provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on September 13, 2023. 
  
You asked the Plan to pay for the refraction. You say that you were told the refraction was needed and you 
were told to pay the $55 upfront. The Plan denied your request. The Plan says the service was not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received during a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided during a medical eye 
examination Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on September 
13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power 
options (K0861) and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair (PWC) with with multiple power options and 
accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the 
items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple options is covered 
when the criteria listed in the Medicare Rules section 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 a group 3 power wheelchair (PWC) 
with with multiple power options and accessories. Our reviewer says that the items are not medically 
necessary. Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a 
catheter intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair (PWC) with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair (PWC) with multiple power options (K0861) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac joint 
(SIJ) (64625). 
 
You asked the Plan to pre-approve RFA for the SIJ. You say that the enrollee had started getting injections due 
to walking and driving a lot for work. You say that it changed your quality of life. You also say that the 
injections will be beneficial to your everyday life activities. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint (SIJ) denervation (also called 
radiofrequency ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA for the SIJ have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) for the sacroiliac joint (SIJ) (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 7, 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 $3,000 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 $3,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have the waive the copayment and coinsurance for the outpatient surgery 
and supplies, rehab services, and occupational therapy, provided on June 23, 2023, through June 30, 2023. 
 
You asked the Plan the waive the copayment and coinsurance for the outpatient surgery and supplies, rehab 
services, and occupational therapy. You say that the services should be covered. 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 40% 
coinsurance for each Medicare covered x-ray, 30% coinsurance for supplies, and 40% coinsurance for each 
Medicare covered outpatient diagnostic procedure and a $40 copay for each physical therapy and occupation 
therapy visit through an out-of-network provider. 
 
You have been asked to pay 40% coinsurance for each Medicare covered x-ray, 30% coinsurance for supplies, 
and 40% coinsurance for each Medicare covered outpatient diagnostic procedure and a $40 copay for each 
physical therapy and occupation therapy visit through an out-of-network provider for the outpatient surgery and 
supplies, rehab services, and occupational therapy. 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 the waive the copayment and 
coinsurance for the outpatient surgery and supplies, rehab services, and occupational therapy, provided on June 
23, 2023, through June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 4 power wheelchair with multiple power 
option, power seat elevation system, power seating system, electronic, and center mount power elevating leg 
rest/platform. 
 
You asked the Plan to pre-approve a Group 4 power wheelchair with multiple power option, power seat 
elevation system, power seating system, electronic, and center mount power elevating leg rest/platform. The 
Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules say that Group 4 PWCs will be denied as not reasonable 
and necessary. The rules also say if the PWC base is not covered, then related accessories will be denied.  
The record shows that the requested Group 4 power wheelchair and accessories at issue in this appeal are being 
requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers 
equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a Group 
4 power wheelchair with multiple power option, power seat elevation system, power seating system, electronic, 
and center mount power elevating leg rest/platform.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a standard microprocessor knee described by
codes L5828, L5848, and L5856 and an endoskeleton knee-shin system described by code L5859.

You asked the Plan to provide coverage for this prosthetic equipment. The Plan denied your request. The Plan
says the Medicare coverage criteria were not met. Maximus partially overturned the Plans denial.

The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
medical records do not show the extent of the comorbidity of the spine or the sound limb which is what is
limiting the enrollee to being a household ambulator. There is no documentation to show how these requested
features will enable the enrollee to function as a community ambulator.

The Plan is correct in this case. 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. The medical records provided do not support the prosthetic components
requested. Therefore, we decided that the Plan does not have to provide coverage for a standard microprocessor
knee described by codes L5828, L5848, and L5856 and an endoskeleton knee-shin system described by code
L5859.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment management. 
 
You asked the Plan to pre-approve radiation treatment management. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 radiation treatment management. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the accurate delivery of radiation therapy can be assured in this case by 
performing accurate set-up and proper immobilization. Moreover, the risk of lymphedema in this scenario 
using the recommended dose fractionation is very low. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment management have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiation treatment management.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 01740. We decided that the 
Plan does not have to pay for the services described by procedure code 99100.  
 
You asked the Plan to pay for the anesthesia services provided on June 22, 2023. You say that medical records 
were provided. The Plan says that code 99100 is always bundled into payment for other services. 
 
We decided that the Plan has to pay for the services described by procedure code 01740.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code 01740 billed for date of service 
June 22, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99100. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code 99100 billed for date of service June 22, 2023. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 10, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 
87563, 87591, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
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 nucleic acid 
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 urine polymerase chain reaction (PCR) panel provided on April 10, 2023, and 
billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 
87481, 87651, and 87653.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 14, 2023, to 
January 20, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J96.20 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says J96.20 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.20, defined as acute 
and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that secondary diagnosis code J96.20 is not supported in the documentation. Our physician 
reviewer found the enrollee presented with a cough, shortness of breath, and weakness in the setting of chronic 
obstructive pulmonary disease (COPD) with home oxygen use. The enrollee was confirmed to have pneumonia 
and a pulmonary embolism (PE) was ruled out. Their signs and symptoms were consistent with baseline COPD 
and acute pneumonia. There is no evidence that the enrollee had acute respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 14, 2023, to January 20, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64447 billed for date of service July 12, 2023. 
 
You asked the Plan to pay for the billed service. You say that this is not a bundled procedure. The Plan denied 
your request. The Plan says that the code is reimbursable if given post operatively. 
 
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 64447 is supported in the medical record. The records show that code 64447 was given 
prior to the enrollees surgical procedure. An epidural or peripheral nerve block injection for postoperative pain 
management may be administered preoperatively, intraoperatively, or postoperatively. Based on this 
information, we decided that Medicare rules for coverage of the billed service have been met. Therefore, we 
decided that the Plan has to pay for procedure code 64447 billed for date of service July 12, 2023.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87634 and 87503 billed for date of service September 22, 2022.

You asked the Plan to pay for procedure codes 87634 and 87503. You say that you disagree with the denial. The Plan denied your request. The Plan says the codes are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87634 is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.

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 87503 is infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure).

We find that CPT code 87503 is not supported in the medical record. Specifically, there is no laboratory report for the date of service at issue supporting that two units of this code were performed. 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 procedure codes 87634 and 87503 billed for date of service September 22, 2022.