Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitoring transmitter (A9277) and a 
continuous glucose monitoring receiver (A9278) provided on July 26, 2023. 
 
You asked the Plan to pay for the continuous glucose monitoring transmitter and receiver. You say that your 
doctor advised you that the items would be covered, and you should not be billed for the equipment. The Plan 
denied your request. The Plan says the billed code is not covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that codes A9276, A9277, A9278, or A9279 and will 
be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitoring transmitter and receiver have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitoring transmitter (A9277) and a 
continuous glucose monitoring receiver (A9278) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for endodontic therapy (D3320) provided on 
August 1, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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. 
 
You have been asked to pay an 80% coinsurance for endodontic therapy. This item/service falls within the 
Dental 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 coinsurance for endodontic therapy 
(D3320) provided on August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a Group 3 power wheelchair with several options.

You asked the Plan to provide coverage for this equipment. The Plan denied your request. The Plan says the
required 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 actual medical
records do not show the enrollee is at high risk for development of pressure ulcer. The enrollee has been using
a manual wheelchair for several years and has no current pressure ulcers and no history of pressure ulcer or
history of flap surgery. The enrollee does not require bladder management and has no documented increased
tone or spasticity issues. The Plan states because the medical records do not show the need for both power tilt
and power recline, the request for K0861 Group 3 power wheelchair with multiple power options is not
reasonable and necessary.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for the requested power wheelchair and accessories. This type of power wheelchair is covered when the
enrollee uses a ventilator mounted to the wheelchair or when the member meets coverage criteria for a power
tilt and power recline seating system. Neither of these conditions applies in this case. Therefore, the
Plan is not required to provide coverage for the requested for K0861 Group 3 power wheelchair with multiple
power options for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on June 14, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 pay for an 
extraction (D7140) provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that you do not want to go to a new audiologist to her 
your hearing aids. The Plan denied your request. The Plan says there are network providers for this item. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are provided by an in-network provider.  
 
We looked at this the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from July 1, 2023, to July 
3, 2023. 
 
You asked the Plan to pay for the medication. You say that this was an emergency, and you had no choice in 
the matter. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from July 1, 2023, to July 3, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 24, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 pay for an 
intraoral x-ray (D0210) provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BDX-XL2 genetic testing rendered on March 17, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that BDX-XL2 testing is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of a 7 
millimeter lung nodule. The BDX-XL testing is covered for the management of a lung nodule, between 8 and 
30 millimeters in diameter, in patients 40 years or older and with a pre-test cancer risk (as assessed by the 
Mayo Clinic Model for Solitary Pulmonary Nodules) of 50 percent or less, per the Medicare rules. The records 
in this case do not document the enrollee meets the criteria. The testing was therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the BDX-XL2 genetic testing rendered on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing rendered on May 29, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that minimal residual disease testing for cancer is 
covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the Guardant Reveal testing is intended 
for colorectal cancer stage II or III. At the time of the testing, it was not clear from the provided records that the 
enrollee had stage II or III colorectal cancer. The records document metastatic cancer with a new liver lesion 
and hypermetabolic lymph nodes, which is highly concerning for stage IV disease and thus not appropriate for 
Guardant Reveal testing. 
 
We looked at this physician's review, the file, and Medicare rules. 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 Guardant Reveal testing rendered on May 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108). 
 
You asked the Plan to pre-approve a transit kit. You say that the requested items are medically necessary. The 
Plan denied your request. The Plan says a transit kit does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a transit kit (K0108).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options (E1028, 
E1007, K0861, E1028, E2300, E0955, E1012, E2311, E2313, E2377, E2361, E2620 and E2622). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the enrollee cannot ambulate and use a cane or walker for mobility. They are unable to propel a manual 
wheelchair due to upper extremity weakness. They cannot use a power scooter given that they are dependent 
with transfers. The enrollee is non-ambulatory and requires a power wheelchair for mobility and performing 
daily activities. They cannot perform pressure relief independently due to upper extremity weakness and 
require a power wheelchair with power tilt and recline for adequate pressure relief and positioning. There is a 
history of skin breakdown. Power elevating leg rests are required for positioning of the lower extremities. The 
complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the three power options. Therefore, the group 3 power wheelchair with 
power tilt & recline and power elevating leg rests is 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 a group 3 power wheelchair with multiple power options have been met. 
Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power 
options (E1028, E1007, K0861, E1028, E2300, E0955, E1012, E2311, E2313, E2377, E2361, E2620 and 
E2622).   

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) for tooth 
#31, endodontic therapy (D3330) for tooth #15, intraorifice barrier (D3911), and therapeutic parenteral drugs 
(D9610) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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 D3330/D3331 was exhausted on date of service August 15, 2023. Therefore, we decided 
that the Plan does not have to pay for the treatment of root canal obstruction (D3331) for tooth #31, endodontic 
therapy (D3330) for tooth #15, intraorifice barrier (D3911), and therapeutic parenteral drugs (D9610) provided 
on August 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 61645 and 99232 provided August 1, 2022, 
through August 2, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records support the billing of procedure 
code 61645-59. The Plan denied your request. The Plan says the medical records do not support the billing of 
procedure code 61645-59. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The Plan follows Medicare rules. The rules say 
that The Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each 
surgical procedure.  If there is an indicator of 000, postoperative visits beyond the day of the procedure are not 
included in the payment amount for the surgery.  
 
In this case, we have confirmed that code 61645 is a column II code to column I code 37215; however, 61645 
was billed with a modifier.  
 
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 the services. Our reviewer found the documentation does not 
support that CPT code 61645 was distinct from CPT code 37215. Furthermore, surgery procedure code 37215 
has a global surgery value of 090 on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) 
file. This is a major procedure that has a global surgery period of 90 days. The initial evaluation code 99232 is included when billed the same day as major surgical procedure 37215, without an appropriate modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 61645 and 99232 provided August 1, 2022, through August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable plastic sideguards (code K0108). 
 
You asked the Plan to pre-approve removable plastic sideguards (code K0108). You say that these items are 
medically necessary. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The specific 
purpose of this item is to protect clothing from road debris and dirt, which is not a medical purpose. Therefore, 
we decided that the Plan does not have to pre-approve removable plastic sideguards (code K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthopantogram provided on July 13, 2023. 
 
You asked the Plan to pay for an orthopantogram. You say that you were told this would be covered. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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 pay for an 
orthopantogram provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 26, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over 
the counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436, 82306, and 84153 billed for date of 
service March 20, 2023.  
 
You asked the Plan to pay for these lab services. You say that you have provided the lab records to support 
payment. The Plan denied your request. The Plan says payment for code 84436 is bundled into payment for 
code 84439. The Plan also says that you billed the remaining codes in dispute with an incorrect Place of 
Service code. 
 
The Plan must follow Medicare rules. In relation to code 84436, 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 84436 is a column two code to column one code 84439 with a modifier indicator of 0. The 
column two code is therefore not payable.  
 
In relation to codes 82306 and 84153, 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. In this case, codes 82306 and 84153 were billed with the laboratory POS code. The records do not 
support that the sample was taken in a laboratory setting. 

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 84436 billed for date of service March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service March 24, 
2023. 
 
You asked the Plan to pay for procedure code A4557. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code A4557 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 A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service March 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 19, 2023, and 
May 20, 2023. 
 
You asked the Plan to pay for the medication. You say that the Plan instructed you to appeal for pharmaceutical 
payment reimbursement. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on May 19, 2023, and May 20, 2023.