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

We decided that the Plan does not have to pay for the complete intraoral x-rays (D0210) and intraoral
periapical x-rays (D0220) rendered on September 8, 2022, and September 19, 2022.

You asked the Plan to pay for these services. Your appeal states you know this benefit was exhausted, however
you had to get a new set with another dentist because the original dentist would not provide you with copies.
The Plan denied your request. The Plan says these services exceed the benefit limit. Maximus partially
overturned the denial for a lack of claim information. The Plan requested a reopen and stated that Maximus did
not apply the correct contract criteria.

The Plan is correct in this case. 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.
The Plan covers one full mouth (complete oral series) x-rays every 36 months and two bitewing and diagnostic
x-rays every calendar year. Your appeal states you knew this benefit was exhausted but think you should be
granted an exception. The file shows that you previously received complete x-rays on June 26, 2022, for which
the Plan approved and paid. The Plan does not make exceptions for exhausted supplemental benefits.
Therefore, we decided that the Plan does not have to pay for the complete intraoral x-rays (D0210) and
intraoral periapical x-rays (D0220) rendered on September 8, 2022, and September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care billed for date of service May 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that bioengineered skin substitutes are only covered 
under certain medical indications. 
 
  
 We looked at the file and Medicare rules. The medical records provided show that the wound graft services 
were provided 3 days after a foot procedure. The records do not document the treatment was provided to a 
chronic wound that failed conservative therapy for at least 30 days. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the wound care billed for date of service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for May 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of an order specifically listing what test(s) were to be 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 code G0483 billed for May 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory panel testing provided on June 27, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that this testing is considered unproven and not medically necessary. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
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 specify whether the ordering physician was in-network with the 
plan. The documentation submitted does not include prior notice from the Plan that this testing would not be 
covered. Without this information, we cannot determine whether the lab order made constituted plan-directed 
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified. 
Therefore, we decided that the Plan has to pay for laboratory panel testing provided on June 27, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 20, 2022, to 
July 22, 2022. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The drugs provided during care in an outpatient hospital facility that are usually self-
administered drugs are not among the types which are covered by Medicare Part B. Therefore, we decided that 
the Plan does not have to pay for the self-administered drugs provided from July 20, 2022, to July 22, 2022.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624R). 
 
You asked the Plan to pre-approve the genicular nerve radiofrequency ablation (RFA). You say that an updated 
knee x-ray indicates a stable right total knee replacement. You also say that this is necessary to treat the 
enrollee's knee pain. The Plan denied your request. The Plan says this is not medically necessary as it is 
considered experimental. 
 
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 radiofrequency 
ablation (RFA). Our reviewer says that the requested genicular nerve RFA is not considered medically 
reasonable and necessary in this case. Our physician reviewer found this service is considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to degenerative 
joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee 
replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore, 
the reviewer found that the requested genicular nerve radiofrequency ablation of the right knee 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 radiofrequency ablation (RFA) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular 
nerve branches including imaging guidance (64624R).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0242U billed for date of service February 4, 2023. 
 
You asked the Plan to pay for procedure code 0242U. You say that this testing was necessary and is supported 
as billed. The Plan denied your request. The Plan says that the code reported does not accurately describe the 
services provided. 
 
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 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 procedure code 0242U. Our reviewer says that this code is 
supported in the documentation provided. Our reviewer found the laboratory order supports code 0242U, as 
there were 54 genes tested, and per the guidelines 0242U should be used when 54-74 genes are tested. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 0242U have been met. Therefore, we decided that the Plan has 
to pay for procedure code 0242U billed for date of service February 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, heel lift.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics, heel lift is medically necessary. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics, heel lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee needs the injection to 
improve their current condition. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria necessary for approval. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that facet joint injections are indicated if there is an absence of non-facet pathology 
per clinical assessment or radiology imaging, including, but not limited to, fracture, infection, significant spinal 
deformity, or tumor. In this case, there is imaging demonstrating T1 and L1 compression fractures which could 
be responsible for the enrollee's back pain. The review has determined that the facet joint injections at issue, in 
this case, are 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that you need this lift chair due to your 
condition. The Plan denied your request. The Plan says you do not meet criteria for this item. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
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 seat lift mechanism. Our reviewer says 
that you do not meet criteria for a seat lift mechanism. Our physician reviewer found the records document generalized osteoarthritis and hemiplegia due to stroke. The records do not show that a seat lift mechanism is 
included in your treating practitioner's course of treatment. You are independent with standing/sitting from a 
rocking oversized bilateral arm electric recliner. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and interlocking non-rotating mounting hardware (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and interlocking 
non-rotating mounting hardware. The Plan denied your request. The Plan says that although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The Plan also says that the headrest accessories coded as 
K0108 are miscoded. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, 
expandable controller, and interlocking non-rotating mounting hardware. Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
the complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. Our reviewer found that the expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options via a joystick. These 
components are required to operate 3 or more power options on a group 3 power wheelchair. Our physician 
reviewer also found that the interlocking non-rotating mounting hardware is also necessary to support the 
enrollee's upper extremity given that it is non-functional from their spinal cord injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, and interlocking non-
rotating mounting hardware have been met. Therefore, we decided that the Plan has to pre-approve an 
electronic connection (E2311), harness (E2313), expandable controller (E2377), and interlocking non-rotating 
mounting hardware (K0108).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy. 
 
You asked the Plan to pre-approve capsule endoscopy. You say that this is recommended for further evaluation 
of the enrollee. 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 capsule endoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has anemia, but no iron studies were provided to support iron deficiency. 
No history of occult or visible gastrointestinal blood loss was provided. Standard of care for evaluation of suspected gastrointestinal bleeding warrants a recent colonoscopy, and if no source is found then 
esophagogastroduodenoscopy. The records do not support that either procedure has been performed within the 
past 2 years. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of capsule endoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a capsule endoscopy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has diabetic retinopathy. The documentation does not support that the enrollee has tried and 
failed bevacizumab. The documentation does not support that bevacizumab would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0481) billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment 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. 
 
We find that CPT code G0481 is not supported. Specifically, a physician order for the drug testing at issue has 
not been provided for review. The services at issue cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of drug testing have not been met.  
  Therefore, we decided that the Plan does not have to pay for drug testing (G0481) billed for date of service 
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on December 15, 2022, to April 19, 
2023. 
 
You asked the Plan to pay for the office visits. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits provided 
on December 15, 2022, to April 19, 2023.