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

 
We decided that the Plan does not have to pay for the bone graft in conjunction with periradicular surgery  per 
tooth, single site (D3428), apicoectomy - molar (first root) (D3425), and retrograde filling - per root (D3430) 
provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you assumed that the line item for oral surgery 
meant any oral surgery and to your surprise the procedure was not covered. You also say you would like a 
reconsideration for the decision and to approve financial help for the procedure. The Plan denied your request. 
The Plan says there is no coverage for apicoectomy, retrograde filling or bone graft. 
 
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 pay for the bone graft in 
conjunction with periradicular surgery  per tooth, single site (D3428), apicoectomy - molar (first root) 
(D3425), and retrograde filling - per root (D3430) provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for pay for arthrotomy, with synovectomy, knee; anterior and
posterior including popliteal area rendered on September 1, 2022.

You asked the Plan to pay for this claim as billed. The Plan denied your request. The Plan says the Medicare
billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that
Maximus did not apply the correct billing criteria. The Plan demonstrated that code 27335-AS-59-RT, an
arthrotomy of the knee with synovectomy for anterior and posterior including popliteal area is documented in
the operative note submitted for review; however, this procedure is considered inclusive to code 27447-AS-RT,
a knee arthroplasty for both medial and lateral compartments with or without patella resurfacing (total knee
arthroplasty), condyle and plateau; therefore the code cannot be verified. The documents received do not
support that the procedure or service was distinct or independent from other services performed; therefore, the
requested modifier is not supported. The requested procedure code is an edited pair with approved code 27447;
it is not separate and distinct, and the coding guidelines reflect this.

The Plan is correct in this case. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare
rules say that providers must report services correctly. In this case, this claim was reported with a billing error
due to the edit relationship between codes 27335 and 27447. Medicare rules for coverage of this claim as billed
have not been met. Therefore, we decided that the Plan does not have to pay for pay for arthrotomy, with
synovectomy, knee; anterior and posterior including popliteal area rendered on September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 6,2022.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating
this testing could be potentially beneficial. The Plan requested a reopen and stated this was not a medical
necessity issue but a billing issue. The Plan demonstrated that the request was for approval of the SelectMDx
biomarker test coded as 0339U Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1,
reverse transcription polymerase chain reaction (RT-PCR). This test was performed on December 6, 2022, by
MDx Health in California. This is a urine-based test to risk-stratify patients at increased risk for prostate
cancer. The submitted medical records show the enrollee was a 69-year-old with a diagnosis of elevated
prostate specific antigen (PSA). The laboratory request form indicates that the Prostate Specific Antigen (PSA)
was 5.1 mg/mL on October 20, 2022. Maximus overturned the denial stating the "the records support that the
criteria for coverage are met." In this case, the Maximus reviewer did not consider whether all of the Medicare
guidelines as outlined the Local Coverage Billing and Coding: MolDX: Molecular Biomarkers to RiskStratify
Patients at Increased Risk for Prostate Cancer A58718, which only lists Progensa PCA3 (81313) and
ConfirmMDx (81551) as tests which have met the coverage criteria of the policy. Review of the technical
assessment indicates that the technical assessment for SelectMDx was not effective until February 17, 2023.
Maximus approved the coverage for SelectMDx performed on December 6, 2022, as meeting the
required criteria. However, SelectMDx did not meet the technical assessment criteria until after this test was
performed. On the date of service, the performance of this SelectMDx test, only Progensa PCA3 and
ConfirmMDx had met the coverage criteria.

The Plan is correct in this case, The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim could not be paid as billed as on the date of service, this
specific testing was not yet covered by Medicare. Therefore, we decided that the Plan does not have to pay for
lab services provided to the enrollee on December 6,2022.
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 you need the CGM to monitor your blood sugar 
levels and it is a better alternative to pricking your finger. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
 
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. Specifically, the documentation from your physician indicates that 
you do not use insulin or have a history of problematic hypoglycemia. 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 pre-approve the surgical placement of implant body (D6010) for 
tooth #31 and the custom fabricated abutment (D6057) for tooth #30 and #31 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the enrollee's benefit for the requested items or services 
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 the Plan pre-approved the surgical placement of implant body (D6010) for tooth #30; therefore, the 
enrollees benefit for the requested items or services was exhausted on the date of approval of September 27, 
2023. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010) for tooth #31 and the custom fabricated abutment (D6057) for tooth #30 and #31
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December
27, 2022.

You asked the Plan to pay for procedure code 76641. You say that the claim is billed correctly and should be
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
Maximus partially overturned the Plan's denial. The Plan requested a reopening and confirmed they approved
payment for procedure codes 77067 and 77063.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 76641 billed for date of service December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2750 x2) and the core build-ups (D2950 
x2). 
 
You asked the Plan to pre-approve the crowns (D2750 x2) and the core build-ups (D2950 x2). You say that 
your front teeth need to be repaired before they peel. You say you are close to choking on the particles. The 
Plan denied your request. The Plan says the core build-ups (D2950) are not covered services and the case was 
auto forwarded. 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the crowns (D2750 x2) and the core 
build-up (D2950 x2) have been met. the provider did not send the medical records. Therefore, we decided that 
the Plan does not have to pre-approve the crowns (D2750 x2) and the core build-ups (D2950 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.

You asked the Plan to pre-approve LTACH services. You say that the enrollee is stable and no longer needs to
remain in a short-term acute care hospital. You say all of the enrollee's needs can be met at a lower LTACH
level of care. The Plan denied your request. The Plan says that the requested LTACH services are not
medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for LTACH services.
Our Medical Director states that the long-term acute care hospitals are certified as acute care hospitals, and in
general, do not provide clinical services that are materially different than those of short-term acute care
hospitals. The available clinical documentation does not support that this enrollee required services at the
LTACH that were not available at the acute care hospital where he was then receiving care. Our Medical
Director found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140). 
 
You asked the Plan to pre-approve the dental service. You say that you need to be seen for a chipped tooth and 
you need a second exam for the tooth. 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 the Plan paid for a limited oral evaluation (D0140) on August 17, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of August 17, 2023. Therefore, we decided that 
the Plan does not have to pre-approve a limited oral evaluation (D0140).
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 due 
to the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is not stable 
enough for transfer at this time. 
 
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 is currently undergoing treatment at an acute care hospital for a traumatic 
brain injury. The enrollee was intubated and ventilated and subsequently received a tracheotomy. The enrollee 
remains on a ventilator in a persistent vegetative state. Ventilator weaning and decannulation are not expected. 
There is no evidence that the enrollee requires services that are not currently available.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dayspring Active Compression System (K1024) and garment 
(K1033). 
 
You asked the Plan to pre-approve the Dayspring Active Compression System and garment. You say that the 
submitted clinical notes support the medical necessity for the requested items. The Plan denied your request. 
The Plan says that based on clinical review, the device worn on the arms or legs to help increase circulation 
(intermittent limb pneumatic compression device) and accessories requested does not meet the requirements for 
approval.  
 
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 the Dayspring Active Compression 
System and garment. Our reviewer says that the requested durable medical equipment is considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee met with Lymphedema 
experts in the management and treatment of the disease. They have recommended the Dayspring compression 
device and there is literature to support its use and improved quality of life and patient care. The enrollee is on 
all other standard therapy without improved symptoms or quality of life therefore this therapy would likely be 
next best practice with literature to support. 
 
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 Dayspring Active Compression System and garment have been met. 
Therefore, we decided that the Plan has to pre-approve a Dayspring Active Compression System (K1024) and 
garment (K1033).  
 
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 pre-approve Oasis Burn Matrix (Q4103). 
 
You asked the Plan to pre-approve Oasis Burn Matrix. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Oasis Burn Matrix. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found with conservative management, one wound got bigger and the other got smaller. 
Documentation suggests a lot of necrotic tissue/eschar, which would be contraindications to use of a skin 
substitute agent.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oasis Burn Matrix have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Oasis Burn Matrix (Q4103).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional routine transportation trip (A0100). 
 
You asked the Plan to pre-approve the additional trip. You say that you do not have medical or other means of 
rides. The Plan denied your request. The Plan says based on a review of the services that have been authorized 
in the current plan year, the benefit maximum has been met for the requested service. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the plan to pre-approve an 
additional trip for a physician visit. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve an additional routine transportation trip (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) (36247). 
 
You asked the Plan to pre-approve PAE. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PAE is not medically reasonable and necessary in this case. PAE is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated 
possible short-term safety and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE) (36247).
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's complex medical needs. The Plan denied your request. The Plan says the enrollee's records do not 
show that it is medically safe for them to go to an LTACH. 
 
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 remains on a ventilator and has poor neurologic status and no signs of 
renal recovery. There is no evidence that the enrollee requires services that are not currently available. The 
enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darzalex, bortezomib, ondansetron, and zoledronic acid. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee is new to this treatment and have not 
tried these drugs prior to submission. The Plan denied your request. The Plan says that the requested drugs are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 drugs. Our reviewer says that 
darzalex, bortezomib, ondansetron, and zoledronic acid are not medically necessary. Our physician reviewer 
found that the requested drugs darzalex, bortezomib, ondansetron, and zoledronic acid are not FDA-approved. 
The requested drugs are also not supported by one of the major drug compendia or by clinical research. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve darzalex, bortezomib, ondansetron, and zoledronic acid.