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

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 7, 2023. 
 
You asked the Plan to pay for dental services. You say that you were in severe pain and called around to in-
network providers. You were told they could not see you for weeks. You say you then had to see an out-of-
network provider. The Plan denied your request. The Plan says this service is not covered under your 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. Core buildup, including any 
pins when required (D2950) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, 
including any pins when required (D2950) provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) x2 
and pontic - porcelain/ceramic (D6245) provided on August 15, 2022. 
 
You asked the Plan to pay for dental services. You say that you were quoted $420 by the provider; however, 
you received a bill for much more than that. You say that you can afford to pay the charges. The Plan denied 
your request. The Plan says these services are not covered under your 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. Core buildup, including any 
pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245) are not covered under the Plans dental 
benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 and D6245 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245) provided on 
August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain continues to worsen. 
The Plan denied your request. The Plan says the enrollee does not have a compression fracture. 
 
The Plan follows Medicare rules. Medicare rules say that a percutaneous vertebral augmentation is only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that there is no documentation that the fractures are less than 6 weeks old. The enrollee has a 
long history of pain and fractures. Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous vertebral augmentation procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the shoulder surgery may be performed safely with a 48-hour observational 
stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) (84443) provided on 
November 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 the thyroid stimulating hormone (TSH) (84443) 
provided on November 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the anesthesia for percutaneous image-guided injection, 
drainage or aspiration procedures on the spine (01938). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the anesthesia for facet joint injections is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions.  
  
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 anesthesia. Our reviewer says that 
the requested service is not medically necessary. Our physician reviewer found that in this case, the request for 
anesthesia for the medial branch blocks is not medically necessary. The submitted documentation does not 
support that separate anesthesia was requested, and there is no documentation of any rare or unique 
circumstances to support the need for anesthesia for this procedure. The review has determined that the 
requested anesthesia is not medically reasonable or necessary in this case. 
 
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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anesthesia for percutaneous image-guided injection, for drainage or aspiration procedures 
on the spine (01938).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to pay for codes 97010 and 97026 provided to the enrollee on October 1, 2021.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided documentation to show the overturned portion of the claim had been paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. Code 97010 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 97010 is not separately payable. In addition, code 97026 is for infrared light therapy, which is not covered for any indication. Based on this information, we decided that Medicare rules for coverage of these codes have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97010 and 97026.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 97010 and 97026 provided to the enrollee on December 31, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and noted that the codes Maximus states were not addressed were denied for no medical records. Those records have since been received and those codes have been paid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, code 97010 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 97010 is not separately payable. In addition, code 97026 is for infrared light therapy, which is not covered for any indication. Based on this information, we decided that Medicare rules for coverage of procedure codes 97010 and 97026 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97010 and 97026.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 medical services provided to the enrollee on December 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux (Cetuximab) for the enrollee.
You asked the Plan to pre-approve Erbitux. You say that Erbitux is medically necessary. The Plan denied your request. The Plan says that this is not being requested for a medically accepted indication.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Erbitux. Our Medical Director states that the there is insufficient support for the use of Cetuximab and Capecitabine in the treatment of Stage IV metastatic adenocarcinoma of the rectum which is positive for KRAS and NRAS wildtype. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Erbitux.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux (Cetuximab) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a computed tomography (CT) scan for treatment planning purposes for the enrollee.
You asked the Plan to provide coverage for a CT scan. You say that at the time of the appeal, the requested CT scan was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Our Medical Director looked at the case file and the reopen request. At issue is coverage for CPT 77014 (Computed tomography guidance for placement of radiation therapy fields).
The Maximus Physician Reviewer determined that the enrollee's cancer was described as being 2 cm in size. The tibia would not be cosmetically sensitive or "poorly vascularized or cartilaginous." 22 fractions of electron beam radiation would fall within the National Comprehensive Care Network (NCCN) guidelines. Protracted fractionation is associated with improved cosmetic results and should be utilized for poorly vascularized or cartilaginous areas. The Plan requested a reopen and stated that both Maximus and the plan reviewer agreed that 22 fractions of radiation should be used. However, the Plan notes that the Maximus reviewer did not address the cone beam CT denial for CPT code 77014. The medical records show the enrollee was a then 89-year-old woman with a left medial tibial squamous cell carcinoma lesion. For planning purposes, CPT 77014 involves the computed tomography scan (CT) in which CT data is collected for dosimetry planning purposes in radiation oncology. CPT 77014 may be utilized for obtaining computerized tomography images utilized for planning purposes when performed separate from the simulation procedure. The Plan is correct in this case. The Plan determined that they would cover G6012 x 22 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev) and G6013 x 22 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev). The Plan denied coverage of 77014 X 1 Computed tomography guidance for placement of radiation therapy fields. The approval of CPT 77014 (Computed tomography guidance for placement of radiation therapy fields) was not presented to the Medical Reviewer for consideration. The clinical documentation does not sufficiently support that CPT 77014 was medically reasonable and necessary for the enrollee in this case. 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 not been met. Therefore, we decided that the Plan does not have to provide coverage for a computed tomography (CT) scan for treatment planning purposes for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292, 81321) provided on June 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
supported in the medical record. 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 (81292, 81321) provided on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified (87798) provided November 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing this decision and 
requesting that this procedure code be reviewed again for payment. The Plan denied your request. The Plan 
says this service is considered experimental or investigational. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee underwent infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique. 87481 and infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified. 87798. Nucleic acid pathogen testing of single pathogen or by panel is 
considered not medically necessary for a urinary tract infection (UTI). Urine culture is the gold standard for 
UTI. The review has determined that the items/services 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique (87481) and infectious agent detection by nucleic acid (DNA or RNA), not 
otherwise specified (87798) provided November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88305 provided to the enrollee on April 18, 2022.
You asked the Plan to pay for procedure code 88305. You say that this service was necessary and is supported in the medical record. The Plan denied your request. The Plan says that the Plan has correctly denied code 88305 for payment. Maximus overturned the Plan's denial. The Plan requested reopening and stated that Maximus did not apply the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that in accordance with code descriptor changes for HCPCS code G0416 effective January 1, 2015, CMS requires that surgical pathology, including gross and microscopic examination, of any and all submitted prostate needle biopsy specimens from a single patient be reported with one unit of service of HCPCS code G0416 rather than CPT code 88305.
We looked at the file and Medicare rules. Medicare rules indicate these services should have been billed with HCPCS code G0416 rather that CPT code 88305. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88305 provided to the enrollee on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99070 and A4649 billed for date of service 
August 23, 2022. 
 
You asked the Plan to pay for procedure codes 99070 and A4649. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 99070 and A4649 are 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 99070 has a status indicator of B on the Physician Fee Schedule. We find that 
code A4649 has a status indicator of P on the Physician Fee Schedule. This means that procedure code 99070 
and A4649 is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 99070 and A4649 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99070 and A4649 billed for date of service August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 
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 99497 is a column II code to column I code 99223. Code 99497 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 99497 
billed for date of service May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. The documentation submitted does not support a significant, 
separately identifiable evaluation and management service to support the use of the -25 modifier. This means 
the 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 99497 billed for date of service August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat treatment with Zilretta (J3304) for the enrollee.
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the safety and effectiveness of repeat treatments have not been demonstrated.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for repeat treatment with Zilretta. Our Medical Director states that there is insufficient support for repeat dosing of Zilretta beyond a single repeat dose. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Zilretta.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat treatment with Zilretta (J3304) for the enrollee.