Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (11721, 99348, 97597) provided on 
August 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services (11721, 99348, 97597) 
provided on August 8, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 16, 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 $1,500 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 19, 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 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 July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified removable prosthodontic procedures, by 
report (D5899 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
unspecified removable prosthodontic procedures, by report (D5899 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) provided on August 4, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium 
(D0367) provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service November 
17, 2022, to November 24, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service November 17, 2022, to November 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty of the upper eyelid with excessive skin. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the photos and visual field testing do not show that vision is restricted. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the photos and visual field testing does not support the medical necessity of this request. In this case, 
the marginal reflex distance is over 3mm bilaterally. The photos and visual fields do not demonstrate visually 
significant loss of the superior visual field due to the eyelids.  
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty of the upper eyelid with excessive skin.
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 if the enrollee is not submitted to an IRF their health 
will greatly deteriorate. The Plan denied your request. The Plan says the IRF services are not medically 
necessary.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 12, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 12, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided 
from March 28, 2022, to April 1, 2022.  
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were admitted 
after surgery. 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. 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 to waive the copayment for the emergency room 
services provided from March 28, 2022, to April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274) and prophylaxis (D1110) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. 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 the periodic oral evaluation (D0120), bitewing x-rays (D0274) and prophylaxis (D1110) provided on 
July 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0480 billed for July 25, 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 that code G0480 is not separately payable. 
 
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. We find that 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 states that code G0480 
cannot be separately paid because an NCCI Procedure-to-Procedure (PTP) edit exists between code G0480 and 
80307. This edit was retracted by Medicare and the NCCI effective July 1, 2023. The Plan has not provided 
any further documentation to support that code G0480 is not payable as billed. Therefore, we decided that the 
Plan has to pay for procedure code G0480 billed for July 25, 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 lab services provided on July 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic for teeth #3 and #4 and crown for teeth #2 and 
#5 (D6740, D6245). 
 
You asked the Plan to pre-approve 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 March 9, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a pontic for teeth #3 and #4 and crown for 
teeth #2 and #5 (D6740, D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on July 19, 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 by claim #: 202308186546529 on date of 
service August 14, 2023. Therefore, we decided that the Plan does not have to pay for core buildup services 
(D2950) provided on July 19, 2023.
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 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 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 July 18, 2023 (D0330). 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 18, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 99205. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99205 is bundled into 
payment for code 96372. 
 
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 99205 
is a column II code to column I code 96372. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 99205 billed for date of service May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept basivertebral nerve ablation. You say that the enrollee's 
primary problem is chronic low back pain due to degenerative disc disease that has resulted in the development 
of vertebrogenic pain identified by degenerative endplates changes frequently known by the eponym modic on 
their magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the Intracept 
basivertebral 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 Intracept basivertebral nerve 
ablation. Our reviewer says that the Intracept basivertebral nerve ablation is not medically necessary. Our 
physician reviewer found that there is no MRI showing only modic changes without facet degenerative joint 
disease. Also, the cause of pain is not clear, and the coverage criteria has not been met. 
 
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 Intracept basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis (L1686) and addition to lower extremity,
pelvic control, hip joint, adjustable flexion, extension, abduction control (L2624) provided to the enrollee on
February 3, 2023.

You asked the Plan to pay for these items. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the documentation requirements have not been met.

Maximus overturned the Plan's denial. The Plan requested a reopening and stated that the necessary
documentation has not been submitted.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid
physician order, proof of delivery and relevant medical records which support medical necessity.

The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records provided do not discuss the need for this item. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for the hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint,
adjustable flexion, extension, abduction control (L2624) provided to the enrollee on February 3, 2023.