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

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 2), custom 
fabricated abutment (D6057 x 2) and abutment supported crown (D5059 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting help from the Plan to 
finish these procedures. 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 Plan's 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 authorization numbers 
A0230110115759 and A0230427000007. Therefore, we decided that the Plan does not have to pre-approve 
surgical access to an implant body (D6011 x 2), custom fabricated abutment (D6057 x 2) and abutment 
supported crown (D5059 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on 
September 7, 2022. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you had no choice but to 
go to urgent care. 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 $40 
copayment for urgently needed services.  
 
You have been asked to pay a $40 copayment for the urgent care services. This item/service falls within the 
urgently needed services 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 urgent 
care services provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on August 30, 2022.
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these
services. 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 Plan's 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 services were exhausted on date of service May 24, 2022.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - resin-based composite -indirect (D2710). 
 
You asked the Plan to pre-approve crown - resin-based composite -indirect. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crown - resin-based composite -indirect (D2710).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint injection. 
 
You asked the Plan to pre-approve a lumbar facet joint injection. You say that a lumbar facet joint injection is 
medically necessary. The Plan denied your request. The Plan says a lumbar facet joint injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 lumbar facet joint injection. Our 
reviewer says that the requested lumbar facet joint injection is not considered medically necessary. Our 
physician reviewer found that the Medicare LCD criteria requires that both sets of diagnostic blocks produce 
80% or more pain relief. This was not achieved. Therefore, the request is deemed not medically reasonable and 
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 a lumbar facet joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954), 
endodontic therapy, premolar tooth (excluding final restoration) (D3320) and retainer crown - porcelain fused 
to high noble metal (D6750) x18 provided on November 5, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like a reconsideration for these services 
because they were needed. 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. Prefabricated post and core in 
addition to crown, endodontic therapy, premolar tooth (excluding final restoration) and retainer crown - 
porcelain fused to high noble metal are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2954, D3320 and 
D6750 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for prefabricated post and core in addition to crown (D2954), endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) and retainer crown - porcelain fused to high noble metal (D6750) x18 
provided on November 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2021, to July 27, 2021, and billed under the Diagnosis Related Group (DRG) 243.
You asked the Plan to pay for the inpatient hospital services under DRG 243. You say that this claim should be paid as billed. The Plan denied your request. The Plan says the records provided do not support the DRG billed.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is the DRG downgrade from 243 (permanent cardiac pacemaker implant with complication or comorbidity) to 244 (permanent cardiac pacemaker implant without complication or comorbidity/major complication or comorbidity).
The medical records show the enrollee was a then 72-year-old man with a history of hypertension and prostate cancer, who presented to the hospital on July 21, 2021, with complete heart block and bradycardia. "Patient did not suffer any consequences of bradycardia/decreased cardiac output." A temporary pacemaker was placed. On July 23, 2021, the enrollee underwent implantation of a permanent pacemaker 2-chamber system without complications. The additional documentation provided supports the DRG downgrade from 243 o 244 (permanent cardiac pacemaker implant without complication or comorbidity/major complication or comorbidity). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2021, to July 27, 2021, and billed under the Diagnosis Related Group (DRG) 243.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 for date of service October 13, 2022. 
 
You asked the Plan to pay for procedure code 99220. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 99220. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the provided records in this case do not 
document a chief complaint, an extended history of present illness, a review of all additional body systems and 
a complete past, family and social history. Therefore, the documentation does not support a comprehensive 
history. Therefore, code 99220 is not supported. 
 
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 99220 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99220 for date of service October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional chiropractic services provided from September 23, 2022, to October 13, 2022.
You asked the Plan to pay for these services. You say that the Plan should provide coverage for more than 30 visits. The Plan denied your request. The Plan says the records show your 30 visits were exhausted prior to the dates of service in question. Maximus overturned the denial for lack of records in the file showing the 30 visits were exhausted. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The Plan covers 30 visits per year. The Plan has provided records to show those visits were exhausted prior to September 23, 2022. Therefore, we decided that the Plan does not have to pay for additional chiropractic services provided from September 23, 2022, to October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) Tooth #7 and 
retainer crown - porcelain/ceramic (D6740) Tooth #8 and 6. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot chew well, so you need the 
requested services approved. 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. This benefit includes the 
requested pontic - porcelain/ceramic (D6245) and retainer crown - porcelain/ceramic (D6740) but is limited to 
up to two implants covered per year, or up to four implants covered per year for edentulous patients. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for crown - porcelain/ceramic (D2740) Tooth #9 and 10, pontic - 
porcelain/ceramic (D6245) Tooth #3 and 5 and retainer crown - porcelain/ceramic (D6740) Tooth #2 and 4. 
Therefore, the pre-approval has exhausted this benefit. Therefore, we decided that the Plan does not have to 
pre-approve pontic - porcelain/ceramic (D6245) Tooth #7 and retainer crown - porcelain/ceramic (D6740) 
Tooth #8 and 6.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper respiratory infection panel (87798, 87502, 87532, 
87498, and 87496) provided on November 30, 2022. 
 
You asked the Plan to pay for the upper respiratory infection panel. You say that this testing was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says this panel was 
not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the upper respiratory infection panel have not been met. Specifically, the service at issue is a test 
panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not 
have to pay for the upper respiratory infection panel (87798, 87502, 87532, 87498, and 87496) provided on 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VIA Disc NP allograft.

You asked the Plan to pre-approve VIA Disc NP allograft. You say that VIA Disc NP allograft is medically
necessary. The Plan denied your request. The Plan says VIA Disc NP allograft is experimental/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 pre-approve VIA Disc NP allograft. Our reviewer
says that the requested VIA Disc NP allograft is not considered medically reasonable and necessary. Our
physician reviewer found that the VIA Disc NP allograft is an experimental procedure. Therefore, the request is
deemed not medically reasonable and 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 VIA Disc NP allograft. have not been met. Therefore, we decided that the Plan
does not have to pre-approve VIA Disc NP allograft.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission 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 noted that the physical therapist's evaluation notes on December 22, 2022, state that the enrollee was walking 100 feet with a four wheeled walker with moderate assistance. The enrollee was transferring with moderate assistance and dressing with moderate assistance. The medical notes from December 22, 2022, state the enrollee's functional level was stable. The records do not indicate the enrollee required daily skilled nursing or daily skilled therapy services at an inpatient SNF level of care.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided, the enrollee's needs were ongoing and custodial in nature and could be provided at a lower level of care. Medicare rules for coverage of SNF care were not met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99495 billed for date of service June 7, 2022.
You asked the Plan to pay for procedure code 99495. You say that this service was necessary and was reported appropriately. The Plan denied your request. The Plan says payment for code 99495 is bundled into payment for code 99496.
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 99495 is a column II code to column I code 99496 with a modifier indicator of 0. The column II code is therefore not payable. 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 99495 billed for date of service June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2022. 
 
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 the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
stating the enrollee meets IRF criteria and their needs cannot be met at a lower level of care. The Plan denied 
your request. The Plan says criteria for admission to the acute IRF setting have not been met. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) and 
extraction (D7210). 
 
You asked the Plan to pre-approve dental services. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
you do not meet criteria for these services. Our physician reviewer found there is inadequate documentation to show that these dental services are medically necessary. Provided records in this case consist of the procedure 
request and dental radiographs with no explanation from the dental provider for the necessity of the requested 
services or consideration for alternative treatment to show its appropriateness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve periodontal scaling and root planing (D4341) and extraction (D7210).