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

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation - new or established 
patient (D0150), intraoral - periapical first radiographic image (D0220), and bitewings - four radiographic 
images (D0274) provided on February 2, 2023. We also decided that the Plan does not have to pay for the 
intraoral - periapical each additional radiographic image (D0230 x2), and cone beam CT image capture with 
field of view of both jaws (D0383) provided on February 2, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D0150, D0220 and D0274. You 
also asked the Plan to pay for the dental services D0230 x2 and D0383. You say that you are requesting 
reconsideration as you had only scheduled an appointment for a cleaning and did not demand this additional 
treatment. 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. This includes the 
dental services represented by D0150, D0220 and D0274. The Plan also says that the dental service represented 
by D0383 is not covered under the dental benefits. The Plan also says your benefit for the intraoral - periapical 
each additional radiographic image D0230 x2, has already been exhausted. You already received the allowed 
frequency of 1 D0220 on the appealed claim. 
 
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 x2 was exhausted 
on date of service February 2, 2023. You already received the allowed frequency of 1 D0220 on the appealed  
claim. The cone beam CT image capture with field of view of both jaws D0383 is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each 
additional radiographic image (D0230x2) and cone beam CT image capture with field of view of both jaws 
(D0383). 
 
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 comprehensive oral evaluation - new or 
established patient (D0150) intraoral - periapical first radiographic image (D0220), and bitewings - four 
radiographic images (D0274), provided on February 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says admission to a SNF does not meet the medical 
necessity requirements for approval.  
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #14 
provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist office told you that the procedures 
would be covered and if you knew that the services would not have been covered you would not have done 
them. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
crowns and core buildup are not covered by the Plan. 
 
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 a crown 
(D2740) and core buildup (D2950) for tooth #14 provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95913) provided on March 16, 
2023. 
 
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 these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the nerve conduction studies (95913) provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis (81270) testing for the enrollee.

You asked the Plan to provide coverage for this testing. You say that this testing should be covered by the Plan.  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 coverage criteria. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis (81270). The medical records show the enrollee was evaluated for an unprovoked DVT and PE in 2021. The Hematology note dated January 9, 2023 states, "Unable to run JAK2 due to denial by insurance." Hemoglobin = 15.6, hematocrit = 46.9, both mildly elevated, did not meet WHO criteria for polycythemia. "Consider JAK2 mutation testing if she meets criteria of polycythemia or experiences characteristic symptoms".  

The Plan is correct in this case. The documentation does not support that the coverage criteria, as established by the LCD, were met in this case. LCD L35000 states, "JAK2 (Janus kinase 2) (eg, myeloproliferative disorder), exon 12 sequence and exon 13 sequence is considered medically necessary in the initial work-up of BCR-ABL and JAK2 (V617F variant) negative adults with clinical, laboratory, or pathological findings suggesting polycythemia vera." "JAK2 V617F genotyping is considered medically necessary in the initial diagnostic work-up of BCR-ABL negative, JAK2-negative adults with clinical, laboratory, or pathological findings suggesting myeloproliferative neoplasm (MPN) (polycythemia vera (PV), essential thrombocythemia (ET) or primary myelofibrosis (PMF)) or a myelodysplastic syndrome (MDS). Note: JAK2 (exons 12 and 13) (reported with 81403) is medically necessary in individuals for whom PV is a strong consideration." 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to provide coverage for JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis (81270) testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230) and the periodontal 
maintenance (D4910) provided by on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never notified before the services 
were done and you do not want to pay for the services. The Plan denied your request. The Plan says your 
benefit for the intraoral radiographic image has already been exhausted. Also, the denial of payment for the 
periodontal maintenance is correct because it is not covered by the Plan. 
 
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 for the intraoral radiographic images (D0220) on November 22, 2022; therefore, the 
enrollees benefit for the intraoral radiographic images was exhausted on the date of service of November 22, 
2022. The periodontal maintenance is not covered under the Plans dental benefit. Therefore, we decided that 
the Plan does not have to pay for the intraoral radiographic image (D0230) and the periodontal maintenance 
(D4910) provided by on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00790) rendered on 
November 30, 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 this denied appropriately. 
 
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 00790 is "Anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified." 
 
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 not supported by the medical records. Our reviewer found that the procedure report describes a sigmoidoscopy was performed. In this case, there is a more appropriate Healthcare Common Procedure Coding 
System (HCPS) code to report for service provided.  
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 00790) rendered on November 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says a SNF admission is 
not medically necessary.  
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 pre-approve 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
spinal canal and of joint of lower extremity.  
 
You asked the Plan to pre-approve the MRI of the lower spinal canal and of joint of the lower extremity. You 
say that the services are medically necessary. The Plan denied your request. The Plan says there has not been 6 
weeks of provider directed treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI of the lower spinal canal and 
of joint of the lower extremity. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the provided records do not document a recent face to face physician appointment with a 
history and examination of the back and hip and an assessment indicating failure of conservative and 
pharmacologic treatment of your pain. There are no medical records indicating the necessity of an MRI scan.  
 
 
 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 MRI of the lower spinal canal and of joint of the lower extremity have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging 
(MRI) of the lower spinal canal and of joint of lower extremity.
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 want to go to the requested facility for your 
rehabilitation needs. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
continue to have a need for skilled therapy; however, you do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You 
can receive further services 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the clinical information provided does not 
support admission to a SNF.  
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided February 3, 2023, to February 
7, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that observation level of care was more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided February 3, 2023, to February 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (code 99233) provided on May 24, 
2022. 
 
You asked the Plan to pay for the physician services. You say that the services provided were necessary. The 
Plan denied your request. The Plan says the claim was submitted with an incorrect place of service 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 and POS code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. However, the POS code on the claim is 31, 
which is a skilled nursing facility. 
 
We find that CPT code 99233 and POS code 31 are not appropriately billed together. Based on this 
information, we decided that Medicare rules for coverage of the physician services  have not been met. 
Therefore, we decided that the Plan does not have to pay for the physician services (code 99233) provided on 
May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for  Dexcom G7 receiver unit and supplies. 

You asked the Plan to provide coverage for a Dexcom G7 unit and supplies. You say that this equipment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial for insufficient in formation in the case file regarding the denial. The Plan requested a reopen and showed that the medical records show you were approved for Dexcom G6 supplies on July 13, 2022. The records do not show you were ever approved for a Dexcom G7 receiver and supplies. The records also show you received a Dexcom G6 receiver on March 31, 2021, which is less than 2 years from the appeal. This is equipment is not yet eligible for replacement and your Dexcom G6 equipment is not reported to be broken, out of warranty or obsolete. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We do not find your Dexcom G6 equipment is not adequate for your use. Medicare does not replace equipment for convenience. Therefore, we decided that the Plan does not have to provide coverage for  Dexcom G7 receiver unit and supplies.