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

 
We decided that the Plan does not have to pay for procedure code 64447 provided on May 25, 2023. 
 
You asked the Plan to pay for procedure code 64447. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is 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 CPT code. 
 
We find that CPT code 64447 is not supported in the medical record. Specifically, the peripheral nerve block is 
not separately payable from the anesthesia services also billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64447 provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310) and panoramic radiographic image 
(D0330) provided on September 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the panoramic radiographic image 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 panoramic radiographic image was exhausted on date of service March 2, 2021. A 
consultation is not a covered service. Therefore, we decided that the Plan does not have to pay for consultation (D9310) and panoramic radiographic image (D0330) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture (D5120) provided on June 
13, 2023. 
 
You asked the Plan to pay for the complete mandibular denture. You say that all your lower teeth were pulled, 
and a new full denture was made. You also say that it had nothing to do with a partial or any previous 
procedures, and the entire denture should be paid by the Plan. 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 March 21, 2019. 
Therefore, we decided that the Plan does not have to pay for the complete mandibular denture (D5120) 
provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided on September 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you and your dental office believed you were 
allowed 2 per year. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 the Plan paid for a periodic oral evaluation (D0120) and a cleaning (D1110) on February 16, 2023; 
therefore, your benefit for the requested items or services was exhausted on the date of service of February 16, 
2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a 
cleaning (D1110) provided on September 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit. provided on September 05, 2023. 
 
You asked the Plan to pay for an office visit.. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for an office visit. provided on September 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on July 29, 2023. 
 
You asked the Plan to pay for an electrocardiogram. You say that you have billed the service at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of an electrocardiogram have been met. 
Specifically, no medical records have been for provided in support of the service at issue. Therefore, we 
decided that the Plan does not have to pay for an electrocardiogram (93010) provided on July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on September 8, 2023. 
 
You asked the Plan to pay 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 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on September 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140 x 10) provided on June 15, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140 x 10) provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. 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.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 14, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (E2103, A4239) provided on August 8, 
2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid relevant medical records which support medical necessity for the supplies provided in this case. The records do not document the need for these items. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for diabetic supplies (E2103, A4239) provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 provided on February 20, 2023. 
 
You asked the Plan to pay for procedure code 64447. You say that this service was medically necessary. The 
Plan denied your request. The Plan says there is insufficient information to support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of procedure code 64447 have been met. 
No medical records were submitted to support the services billed. Therefore, we decided that the Plan does not 
have to pay for procedure code 64447 provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 microprocessor knee and K3 foot (L5856, L5828,
L5848, L5845 and L5981) for the enrollee.

You asked the Plan to pre-approve this prosthetic equipment. You say that at the time of the appeal, this
prosthetic equipment was medically necessary. The Plan denied your request. The Plan says the documentation
provided does not establish medical necessary. 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 medical records state specific documentation to show the enrollee is a K3
ambulator is required for coverage. The available clinical documentation in the case file does not support that
the enrollee in this case had a functional level or K3 or above. Medicare coverage criteria are not met.
Therefore, we decided that the Plan does not have to pre-approve a K3 microprocessor knee and K3 foot
(L5856, L5828, L5848, L5845 and L5981) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85610) provided on September 26, 2023. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test was for screening purposes on non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, Prothrombin Time, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
lab services (85610) provided on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by code 99350 performed on date of service September 6, 2023. 
 
You asked the Plan to pay for 99350. You say that 99350 should be paid as billed because this service was 
medically necessary and is supported in the medical record. The Plan denied your request. The Plan says 99350 
is denied because it was billed with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 99341-99350 are used to report E&M 
services furnished to enrollees residing in their home, an assisted living facility, a group home, a custodial care 
facility, or a residential substance abuse treatment facility. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 99350 was billed on the claim with 
POS code 31, indicating services were rendered at a skilled nursing facility. Per Medicare rules, codes 99341-
99350 are used to report E&M service furnished to enrollees residing in their home, an assisted living facility, a 
group home, a custodial care facility, or a residential substance abuse treatment facility. As such, the denial of 
99350 billed with POS code 31 is appropriate. Based on this information, we decided that Medicare rules for 
coverage of 99350 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management (E&M) services described by code 99350 performed on date of service September 
6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Vabysmo intravitreal injections for the
enrollee.

You asked the Plan to provide coverage for Vabysmo intravitreal injections. The Plan denied your request. The
Plan says the required coverage criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information.

The Plan is correct in this case. Medicare covers Part B medications when they are reasonable and necessary
but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented
such criteria for certain Part B medications. 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 preapprove
Vabysmo intravitreal injections. Our reviewer says that the required coverage criteria were not met.
Our physician reviewer found the required step-therapy of the plan's required drug Byooviz would likely not be
less effective or have more adverse effects for the enrollee than Vabysmo. Byooviz is a biosimilar of the drug
Ranibizumab, which is FDA approved for the treatment of the enrollee's condition. Biosimilar medications
show similar efficacy and safety to the original medication. Medicare coverage criteria were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vabysmo intravitreal injections have not been met. Therefore, we decided that
the Plan does not have to provide coverage for Vabysmo intravitreal injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87491, 87798, 87500, 87641) provided on 
September 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation did not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87491, 87798, 87500, and 87641 are not supported in the medical record. Specifically, 
the lab order provided does not support the codes billed. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (87491, 87798, 87500, 87641) provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive 
pulmonary disease (COPD) and no trial or failure of bilevel positive airway pressure (BIPAP) therapy, with or 
without average volume-assured pressure support (AVAPS). The enrollee may benefit from BIPAP therapy, as 
that is to be determined, however, there is no indication per documentation nor data, to suggest need for a home 
ventilator at this junction. Hence, there is no indication for a home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 18, 
2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you do not feel you were 
inpatient on this date. 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 $175 
copayment for inpatient hospital care. 
 
You have been asked to pay a $175 copayment for an acute inpatient stay. This item/service falls within the inpatient hospital care 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. You have been asked to pay a total of $175 for the inpatient hospital stay ($175 copayment 
x 1 days = $175). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on July 18, 2023, to July 21, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 29, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on September 14, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for physicians services provided on September 14, 2023.