Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the enrollee has tried and failed conservative 
therapy. The Plan denied your request. The Plan says this procedure 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging showing only Modic endplate changes without facet 
degenerative joint disorder or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness
(E2313), electronic connection (E2311) and power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve an expandable controller upgrade, harness, electronic connection and power
seat elevation feature. You say that these items are medically necessary. The Plan denied your request. The
Plan says that while the member's arm strength is limited, the member will not be operating the wheelchair.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller upgrade, harness and electronic connection. Our Medical Director states that the documentation
supports that attendant control was approved, and the enrollee will not be operating the wheelchair. Our
Medical Director found that the enrollee's condition does not meet criteria for coverage of an expandable
controller upgrade, harness and electronic connection.
We looked at this physician's review, the file, and Medicare rules. A power seat elevation feature is a noncovered
because it not primarily medical in nature. Based on this information, we decided that Medicare rules
for coverage of an expandable controller upgrade, harness, electronic connection and power seat elevation
feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable
controller upgrade (E2377), harness (E2313), electronic connection (E2311) and power seat elevation feature
(E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that the enrollee qualifies based on their
condition. The Plan denied your request. The Plan says that this is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the available documentation is limited and is insufficient to
support that the electronic connection device (E2311) for a power wheelchair was medically reasonable and
necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not meet
criteria for coverage of an electronic connection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided from August 25, 2022, to
October 18, 2022.
You asked the Plan to pay for the acupuncture services. You say that each time you go, the same services are
given, and there is no reason to start denying portions of your bills. The Plan denied your request. The Plan
says that you have exhausted this benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
Though the Plan offers an acupuncture 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 August 23, 2022.
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from August
25, 2022, to October 18, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit, and electrocardiogram (EKG)
provided to the enrollee on June 11, 2022.
You asked the Plan to pay for the emergency room visit and EKG. You say that the enrollee was seen twice on
the same date of service by two different providers. The Plan denied your request. The Plan says that they
already paid this service under another claim for the same date of service and same physician group.
The Plan must follow Medicare rules. Medicare rules state that if more than one evaluation and management
service is provided on the same day to the same patient by more than one physician in the same specialty and
group, only one evaluation and management service may be reported unless they are for unrelated problems.
The record shows that these evaluation and management services were performed for a related problem to an
evaluation and management service performed on the same date of service by another physician of the same
specialty group practice which was already paid by the Plan. Therefore, we decided that the Plan does not have
to pay for the emergency room visit, and electrocardiogram (EKG) provided to the enrollee on June 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns for teeth #'s 3 and 31.
You asked the Plan to pre-approve the dental crowns. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item or service has
already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided
additional documentation.
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 crown on tooth #3 was exhausted on date of service February 11, 2020, and was
exhausted for tooth #31 on June 23, 2020. Therefore, we decided that the Plan does not have to pre-approve
dental crowns for teeth #'s 3 and 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 PWC with multiple power options (K0862)
and accessories/attachments for the enrollee.
You asked the Plan to pre-approve these services. You say that criteria for coverage have been met. The Plan
denied your request. The Plan says that the requested power wheelchair and accessories are not medically
necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 PWC
with multiple power options (K0862) and accessories/attachments. Our Medical Director states that the
documentation in the case file is insufficient to support that the enrollee in this case meets the coverage criteria
for a group 3 power wheelchair (PWC) with multiple power options (power tilt and power recline) and
accessories/attachments. Our Medical Director found that the enrollee's condition does not meet criteria for
coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Group 3 PWC with multiple power options (K0862) and accessories/attachments for the
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service is not supported for separate 
payment. 
 
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 87634 is a column II code to column I code 87798; however, 87634 
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 procedure code 87634. Our reviewer says that this service is 
not supported for separate billing. Our reviewer found although this procedure was reported with modifier -59 
(distinct procedural service), the laboratory report does not include documentation to support that this 
procedure was distinct from the billed CPT 87798.  
 
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 87634 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87634 billed for date of service October 27, 2022.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for procedure code 33999 billed for date of service October 10, 2022.

You asked the Plan to pay for the billed services. You say that the service is separately payable. The Plan denied your request. The Plan says that the code is included in CPT code 33208.

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 find that there are no code edits between 33208 and 33999. Based on this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure code 33999 billed for date of service October 10, 2022.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lesion removal provided on March 1, 
2023. 
 
You asked the Plan to waive the copayment for the lesion removal. You say that you were never in the hospital. 
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 $350 
copayment for in-network outpatient surgery provided at an outpatient hospital.  
 
The record shows this service was provided at an outpatient hospital. You have been asked to pay a $350 
copayment for the lesion removal. This item/service falls within the outpatient surgery 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 lesion removal provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the medical eye exam, the ophthalmic 
biometry, and the scanning computerized ophthalmic diagnostic imaging provided by an out-of-network 
provider on March 7, 2023. 
 
You asked the Plan to waive the deductible for the eye exam, the ophthalmic biometry, and the ophthalmic 
diagnostic imaging. You say that your Plan should cover out-of-network services. 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. Your 
contract with the Plan says that there is a $950 deductible which applies to out-of-network vision care services. 
 
You have been asked to pay a $270.75 deductible for the medical eye exam, the ophthalmic biometry, and the 
scanning computerized ophthalmic diagnostic imaging ($172.94 + $54.71 + $43.10 = $270.75). The items or 
services you asked the Plan to waive the deductible for were provided by an out-of-network provider. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $950 deductible which applies 
to out-of-network vision care services. This cost sharing is a contractual obligation that had not been met at the 
time the eye exam, the ophthalmic biometry, and the ophthalmic diagnostic imaging were provided on March 
7, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the medical eye exam, 
the ophthalmic biometry, and the scanning computerized ophthalmic diagnostic imaging provided by an out-of-
network provider on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction the bone replacement graft - retained 
natural tooth - first site in quadrant (D4263), retainer crown - porcelain/ceramic (D6740), prefabricated post 
and core in addition to crown (D2954), crown - porcelain/ceramic (D2740), pontic - porcelain/ceramic (D6245) 
and retainer crown - porcelain fused to high noble metal (D6750). 
 
You asked the Plan to pre-approve the dental services represented by codes D4263, D6740, D2954, D2740, 
D6245 and D6750. You say that you are extracting tooth 25 and adding bone and the enrollee would need a 
bridge to cover the space for tooth 25. They are extending bridge to tooth 23 because tooth 24 is not strong 
enough to support bridge. The Plan denied your request. The Plan says the requested services are 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 the dental 
services represented by codes D4263, D6740, D2954, D2740, D6245 and D6750 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 the dental services represented by codes 
D4263, D6740, D2954, D2740, D6245 and D6750. Our reviewer says that the requested dental services are not 
medically necessary. Our physician reviewer found the dental services are not medically necessary as the teeth 
that these procedures are associated with have a guarded to poor prognosis. The enrollee has periodontal 
disease as noted from the periodontal charting and bone loss is evident around these teeth as seen on the x-rays. 
A dental bridge, which the general dentist is asking to be authorized is not recommended for these teeth. The 
prognosis of teeth based off of periodontal health should be included in the treatment planning for the enrollee. 
 
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 the dental services represented by codes D4263, D6740, D2954, D2740, D6245 
and D6750 have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone 
replacement graft - retained natural tooth - first site in quadrant (D4263), retainer crown - porcelain/ceramic 
(D6740), prefabricated post and core in addition to crown (D2954), crown - porcelain/ceramic (D2740), pontic 
- porcelain/ceramic (D6245) and retainer crown - porcelain fused to high noble metal (D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641 billed for date of service January 6, 
2023. 
 
You asked the Plan to pay for procedure code 87641. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 87641 is bundled into 
payment for code 87801. 
 
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 87641 
is a column II code to column I code 87801. This 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 87641 billed for date of service January 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the enrollee has failed non-surgical treatment. 
You say that the pain causes significant impact on the enrollee's daily functioning. You also say that the 
enrollee meets Medicare criteria for vertebral augmentation according to Medicare LCD L38213 which 
supports stabilization of an osteoporotic fracture when clinically indicated. The Plan denied your request. The 
Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty procedure will be considered 
reasonable and necessary when certain 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 the kyphoplasty. Our reviewer says that 
the requested kyphoplasty is not medically necessary. Our physician reviewer found the provided 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on the 
enrollee's daily activities. The reviewer found there is magnetic resonance imaging (MRI) corroboration of 
other plausible causes of pain. Therefore, the reviewer found that the requested kyphoplasty is 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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an outpatient L1 kyphoplasty (22514).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 33999 billed for date of service October 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the service is separately payable. The Plan 
denied your request. The Plan says that the code is included in CPT code 33208. 
 
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 find that there are no code edits between 33208 and 33999. Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for procedure code 33999 billed for date of service October 10, 2022.  
 
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.