Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
1, 2021, to December 23, 2021. 
 
You asked the Plan to pay for SNF care. You say that you should only be responsible for December 21, 2021, 
to December 23, 2021, for copay.  The Plan denied your request. The Plan says you did not meet the criteria for 
the SNF stay between December 17, 2021, to December 23, 2021. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 1, 2021, to December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and the protective restoration (D2940) provided on January 5, 2023. 
 
You asked the Plan to pay for this item/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 item/service are not covered under the 
supplemental dental policy.  
 
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, the item/service provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950) and the protective restoration (D2940) provided on  
January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing has been documented. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the 
medical record. Train of Four Testing does not fit the criteria set by CMS and Insurance Carriers for code 
95937. There is no separate code for Train of Four Monitoring, therefore, it would be inappropriate to bill the 
neuromuscular junction testing code for Train of Four Monitoring. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 95937 billed for date of service December 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because your records show that your fracture is greater 
than 12 weeks old. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found there is no trial and failure of fracture 
bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
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 June 12, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it is 
supported in the medical record. 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 June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bag hook, special seat size 19" W x 23" D, Gyro set 
vigo kit, Gyro set Cubo mounting set for omni 2, and Gyro set Cubo mounting set for Qlogic (K0108).  
You asked the Plan to pre-approve a bag hook, special seat size 19" W x 23" D, Gyro set vigo kit, Gyro set 
Cubo mounting set for omni 2, and Gyro set Cubo mounting set for Qlogic. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bag hook, special seat size 19" W x 23" D, Gyro set vigo 
kit, Gyro set Cubo mounting set for omni 2, and Gyro set Cubo mounting set for Qlogic (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), 
and an expandable controller (E2377). 

You asked the Plan to pre-approve an electronic connection, harness, and an expandable controller. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 an electronic connection, harness, and 
an expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found provided records document that the 
enrollee has 3+/5 bilateral upper extremity strength with pinch and grip strength reported as "WFL" [within 
functional limits]. He is reported to be independent with feeding. These records overall support that the enrolle 
has adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. Documentation from the physician does not support that the enrollee requires all the upgraded 
electronics requested. 
 
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, harness, and an expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), harness for upgrade to 
expandable controller (E2313), and an expandable controller (E2377).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for codes 87481, 87491, 87591, and 87801 billed for June 25, 2023. 
 
You asked the Plan to pay for codes 87481, 87491, 87591, and 87801. You say that these are distinct services 
and they required separate reimbursement. The Plan denied your request. The Plan says that these tests aren't 
documented in the records provided. 
 
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 87481 is infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella 
quintana, amplified probe technique. The definition of 87491 is infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 87591 is infectious agent 
detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique. The definition of 
87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) 
technique. 
 
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 codes 87481, 87491, 87591, and 87801. Our reviewer says 
that these codes are documented in the records. Our reviewer found the records document a urinary tract 
infection panel, and these specific tests were performed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87481, 87491, 87591, and 87801 have been met. Therefore, we decided 
that the Plan has to pay for codes 87481, 87491, 87591, and 87801 billed for June 25, 2023.  
 
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 pre-approve arthrodesis (22612) and posterior non-segmental 
instrumentation (22840). 
 
You asked the Plan to pre-approve arthrodesis and posterior non-segmental instrumentation. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 arthrodesis and posterior non-segmental 
instrumentation. 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 documentation of spinal instability on 
flexion extension radiographs showing more than 5 millimeters of motion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis and posterior non-segmental instrumentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22612) and posterior non-
segmental instrumentation (22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97811 billed for date of service February 9, 
2023, to February 20, 2023.  
 
You asked the Plan to pay for procedure code 97811. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 97811 is 2. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 97811 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 97811 billed for date of service February 9, 2023, to February 20, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on April 19, 2023. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you disagree 
with the cost share. 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 $100 
copayment for Medicare-covered diagnostic test and procedures at an outpatient hospital setting.  
 
You have been asked to pay a $100 copayment for the myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) provided on March 21, 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 that your benefit for the requested item or service 
has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) provided on 
March 21, 2023.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 CDx liquid biopsy (0242U) provided to the
enrollee February 27, 2023.

You asked the Plan to pay for this testing. The Plan denied your request. The Plan says the 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 clinical documentation shows the enrollee
had a lumpectomy with lymph node biopsy on June 1, 2015. As the documentation shows that tissue based
comprehensive gene profiling from a recent biopsy is feasible, testing with liquid biopsy is only appropriate
where solid tissue failed or was not feasible.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of testing. As the documentation does not include failure of solid tissue testing or that solid tissue
testing was not an option, Medicare coverage criteria were not met. Therefore, we decided that the Plan does
not have to pay for the Guardant 360 CDx liquid biopsy (0242U) provided to the enrollee February 27, 2023
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve 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 noted 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.
Review of the medical records at the time of the appeal show your needs were custodial in nature. You did not
require skilled nursing or skilled therapy services daily at an inpatient level of care. Medicare coverage criteria
were not met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF)
care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF 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 noted 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 IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section.

Based on review of the medical records provided, the enrollee did not require daily skilled nursing and daily
skilled therapy services at an IRF level of care. Therefore, we decided that the Plan does not have to provide
coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you never had a crown on your tooth, so 
this service should be 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a white glass with high gold content crown (D2750) on date of service September 10, 
2021. Therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a crown - porcelain fused to high noble metal (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning (D1110) provided on July 10, 2023. 
 
You asked the Plan to pay more 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 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 cleaning (D1110) provided on July 10, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injections to be provided by an OON provider.  
 
You asked the Plan to pre-approve the injections. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the injections to be provided by an OON provider.