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

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on March 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told how much this would cost. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual maximum benefit of $1,000 was exhausted on date of service March 15, 2023. Therefore, 
we decided that the Plan does not have to pay for a core build-up (D2950) provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on June 29, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as you 
have not provided valid proof of payment.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have not provided valid proof of 
payment for the gym membership purchased in this case. Specifically, the documentation provided does not 
clearly show that you have paid for this membership. Therefore, we decided that the Plan does not have to issue 
reimbursement for the health club membership (S9970) purchased on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
prophylaxis (D1110), and an unspecified preventive procedure (D1999), provided on September 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like the Plan should pay for some 
of this. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120), 
bitewings (D0274), prophylaxis (D1110), and an unspecified preventive procedure (D1999), provided on 
September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional extractions and immediate maxillary/mandibular 
dentures (D7210, D7140, D5140, D5130) provided on March 3, 2022, to April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for additional extractions and immediate 
maxillary/mandibular dentures (D7210, D7140, D5140, D5130) provided on March 3, 2022, to April 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on February 15, 2023, by 
an out-of-network (OON) provider.  
  You asked the Plan to pay for the home health services. You say that the facility is responsible for obtain 
authorization and the services were rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the services rendered 
were not urgent or emergent. 
 
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 home health services provided on February 15, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic material to aid in tissue regeneration (D4265) 
provided on November 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the dental dental service 
because the provider did not accept the medical plan for the performed surgery. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because the biologic material to aid in tissue 
regeneration is not covered by the 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
biologic material to aid in tissue regeneration (D4265) provided on November 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with diagnosis code 
A41.9 rendered from February 17, 2022, to February 24, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism). In this case, the documentation 
does not consistently and completely support the assigned secondary diagnosis code. The decision to remove 
the secondary diagnosis code and adjust the DRG is upheld.  
 
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 reported with diagnosis code A41.9 rendered from February 17, 2022, to 
February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a temporary cap (D6793), provided on February 16, 20, to 
February 17, 2023. 
 
You asked the Plan to pay for D6793. You say that you needed this dental work. The Plan denied your request. 
The Plan says the denied service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a 
temporary cap (D6793), provided on February 16, 20, to February 17, 2023.
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 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. The medical records show that at the time of the request, the enrollee was not stable to transfer to a SNF facility and required ongoing inpatient care. Medicare will only cover SNF care for enrollees eligible to be transferred and appropriately treated in a SNF environment, which is a lower level of care than inpatient admission. As the medical records show the enrollee was not stable for transfer to a SNF at the time of the appeal, Medicare coverage criteria 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2150) for tooth #31 
provided on March 21, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were told that the dental services 
would be covered. The Plan denied your request. The Plan says you are responsible for the difference in 
allowed amount and the proper cost share was applied. 
 
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 original allowed amount for the resin-based composite (D2392) was $190. The total allowed amount for 
the approved resin-based composite (D2150) was $134. The difference in the allowed amount was $56 ($190 
billed - $134 approved). The total amount for the coinsurance was $26.80 ($134 allowed x 20% coinsurance). 
The total amount you are responsibility for is $82.80 ($56 difference + $26.80 coinsurance). 
 
You have been asked to pay the difference between the allowed amount of the less expensive alternate 
procedure and the coinsurance amount. 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 pay more for the resin-based 
composite (D2150) for tooth #31 provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and related 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the enrollee does not 
have a qualifying diagnosis for a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy, or congenital skeletal deformity. As the PWC base is not medically necessary for the enrollees 
condition, the requested accessories are not covered. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair (K0861) and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code E87.1 
rendered from July 26, 2021, to July 29, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the partial recoupment that adjusted the DRG. The Plan denied your request. The Plan says a post-
service, post-payment Clinical Validation Audit was performed to ensure that the diagnosis codes on the claim 
supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code E87.1. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of E87.1 (Hypo-osmolality and hyponatremia). In this case, the 
documentation does not consistently and completely support the assigned secondary diagnosis code. The 
decision to remove the secondary diagnosis code and adjust the DRG is upheld.  
 
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 billed with diagnosis code E87.1 rendered from July 26, 2021, to July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not suspected of having 
either AD or FTD. The only pertinent diagnosis noted is mild cognitive impairment (MCI). As the enrollee 
does not meet diagnostic criteria for both AD and FTD, the initial requirement of the NCD cannot be satisfied 
at this time. Therefore, this request would not meet Medicare criteria for coverage. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(procedure code 95940) rendered on June 9, 2022. 
 
You asked the Plan to pay for the services. You say that the attached medical records should be reviewed. The 
Plan denied your request. The Plan says Current Procedural Terminology (CPT) 95940 remains 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 95940 is "Continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure)." 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that codes 95940, 95941 and G0453 
are considered incidental to the surgeon's or anesthesiologist's primary service and not eligible for separate 
reimbursement when performed and billed by the surgeon or anesthesiologist. G0453 will not be allowed when 
billed during the same operative session as 95940 or 95941. Modifier XP cannot be verified, as this procedure 
is inclusive to the primary procedure code. 
 
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 continuous intraoperative neurophysiology monitoring (procedure code 95940) rendered on 
June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission to regain 
maximum function. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palonosetron hcl (J2469). 
 
You asked the Plan to pre-approve palonosetron hcl. You say that this is medically necessary for treatment of 
the enrollee's liver cancer. The Plan denied your request. The Plan says the use of this drug is not reasonable 
and 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 palonosetron hcl. Our reviewer says 
that the use of palonosetron hcl is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found 
the use of palonosetron hcl is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of palonosetron hcl have not been met. Therefore, we decided that the Plan does 
not have to pre-approve palonosetron hcl (J2469).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for  a pneumatic compression device provided on October 25, 2022. 

You asked the Plan to pay for  this device. You say that this device 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. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a pneumatic compression device. The medical records show you have a diagnosis of lymphedema. The cardiology notes dated June 9, 2022, documents a history that includes chronic lower extremity edema. The notes state "His edema has slightly improved with recent changes in his diuretics by his primary care physician." 2+ lower extremity edema is documented on exam. It was recommended that the enrollee follow-up in the lymphedema clinic and wear compression stockings. A note from July 20, 2022, from cardiology states the edema has slightly improved. A note from cardiology on August 19, 2022, states "2+" pedal edema. A note from cardiology on August 29, 2022, stated there was bilateral lower extremity edema. Extremities with no clubbing, cyanosis, edema, or tenderness.  There is no evidence of lower extremity chronic venous insufficiency. A note from outpatient rehabilitation on September 7, 2022, show improvement of bilateral edema.  The Plan is correct in this case. The Medicare LCD L33829 states that a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the requirements are met. The clinical documentation does not support that the LCD criteria for a PCD were met as there is documentation of improvement with clinical treatment over the course of a required four-week trial. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pay for  a pneumatic compression device provided on October 25, 2022.