Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has stabilized and is ready 
for discharge from the acute care hospital. You say that the enrollee needs to be transferred to an LTACH to 
regain maximum prior level of functioning and continue multi-disciplinary approach to care. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve ablation. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that the enrollee is still in pain and the 
procedure is necessary to prevent hospitalization. The Plan denied your request. The Plan says the genicular 
nerve ablation 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 genicular nerve ablation. Our 
reviewer says that the genicular nerve ablation is not medically necessary. Our physician reviewer found that 
genicular nerve blocks and genicular nerve ablations are considered investigational and not medically 
necessary for the treatment of chronic knee pain. Therefore, the requested genicular nerve ablation for right 
knee pain is not medically reasonable or necessary.  
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 nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 27, 2023. 
 
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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 25, 2023. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 27, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 1, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not in hospice at the time 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on June 1, 2023.
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 July 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you could 
not sleep and you thought you were having a panic attack. You also say that the emergency medical services 
took your vitals and checked your blood sugar with your device and you declined the transport to the hospital. 
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 July 30, 2023. 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 July 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248). 
 
You asked the Plan to pre-approve the dental services. You say that your provider is recommending this type of 
sedation with your extractions. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental 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 pre-approve non-
intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
5, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were charged for an evaluation and a 
cleaning, but you did not get an evaluation. You say they only cleaned your teeth, and you don't think you 
should have to pay for it. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 16, 2023. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 5, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provide don January 31, 2023, to, 
March 23, 2023. 
 
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says the 
acupuncture services were provided by an unqualified provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services provide don January 31, 2023, to, March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 skilled nursing visits. 
 You asked the Plan to pre-approve the skilled nursing visits. You say that they have put the enrollee on weekly 
and they are needing skilled nursing visits for the certification period. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided the health plans denial should be upheld. The enrollee does not have documented 
skilled nursing needs. As such, the requested, ongoing services are not medically necessary or reasonable. If 
the enrollee has a newly diagnosed cancer, which they are opting not to treat, they may be eligible for Hospice 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 20 skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 45378 billed for date of service February 1,
2023.

You asked the Plan to pay for procedure code 45378. You say that this should be paid for. The Plan denied
your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess
units. Maximus overturned the Plan's denial. The Plan requested a reopening and indicated criteria for
coverage have not been met.

In this case, the MUE for CPT code 45378 is 1. The MAI value for this code is 3. You billed 2 units of this
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided
that Medicare rules for coverage of procedure code 45378 have not been met. Therefore, we decided that the
Plan does not have to pay for procedure code 45378 billed for date of service February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on April 25, 2023.
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 June 4, 2023. 
 
You asked the Plan to pay for procedure code 99053. You say that you are requesting the claim be reviewed 
and reprocessed for payment. 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 June 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2391) provided on February 27, 2023. 
 
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 the claim was 
filed untimely. 
 
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 records 
provided show that the claim for payment was submitted on August 16, 2023. This is more than 120 days from 
February 27, 2023. Therefore, the rules for coverage have not been met and the Plan does not have to pay for a 
filling (D2391) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and gingival irrigation with a medicinal 
agent (D4921, D0210) provided on August 2, 2023. 
 
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 your benefit for intraoral x-rays has already been 
exhausted. Moreover, overage for the gingival irrigation with a medicinal agent 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 Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 5, 2020 (D0210). 
Coverage for the gingival irrigation with a medicinal agent denied correctly as they do not fall within your 
dental benefits. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray and gingival 
irrigation with a medicinal agent (D4921, D0210) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown-porcelain/ceramic (D2740) provided on August 17, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you received a crown back in 2021 however, 
you woke up in August, 2023 with the crown falling apart in your mouth. You feel the crown was defective and 
that it should have lasted longer than two years. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 29, 2021. 
Therefore, we decided that the Plan does not have to pay for a crown-porcelain/ceramic (D2740) provided on 
August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the level of care needed to ensure a safe discharge. The Plan denied your request. The 
Plan says when the enrollee is ready to leave the hospital, they can receive their care in a skilled nursing facility 
or at home with home health services. 
 
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 the enrollee's course has been complicated. Given the pace of the enrollee's recovery, 
it is not expected that they will require 25 days in LTACH. Completion of treatment in the current facility is 
recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you are in a lot of pain and need to 
the injections to improve your quality of life and so that you can walk. The Plan denied your request. The Plan 
says the genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that you have a 
history of bilateral knee pain due to osteoarthritis. However, genicular nerve blocks and genicular nerve 
radiofrequency ablations are considered investigational and not medically necessary for the treatment of 
chronic knee pain.  
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 nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says that the evidence is 
insufficient to determine if enrollees is over 77 years would benefit from low dose CT screening for lung 
cancer. This does not mean this is restricted from receiving the service, it only means that the service will not 
be covered by their Medicare plan. the enrollee  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that this 
service is medically necessary. Our physician reviewer found the enrollee falls into the age group of LDCT 
screening for lung cancer per revised USPTF guidelines. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan.  
 
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 extractions and deep sedation/general anesthesia (D9222, 
D9223, D7210) provided on July 18, 2023. 
 
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 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. 
 
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 extractions and deep sedation/general anesthesia (D9222, D9223, D7210) provided on July 18, 2023.