Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the services. We decided that the Plan does not have to pre-
approve core buildup and crown for tooth #12.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that the 
records do not show any decay that has come back under the crown. 
 
We decided that the Plan has to pre-approve core buildups (D2950) and crowns (D2740) for teeth #'s 13 
and 15.  
 
 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. The Plan covers the services 
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 for the services. Our reviewer says that a review of the 
documentation indicates that the defective bridge replacing tooth #14 was removed and a root canal was 
completed on tooth #15. The removal of the bridge rendered the crowns on teeth #'s 13 and 15 not salvageable. 
Core buildups on teeth #13 and 15 and replacement crowns are medically reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-
approve core buildups (D2950) and crowns (D2740) for teeth #'s 13 and 15.  
 
We also decided that the Plan does not have to pre-approve core buildup and crown for tooth #12. 
 
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. The Plan covers the services 
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 for the services. Our reviewer found that the 
documentation does not support the need for a core buildup and crown for tooth #12. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of core buildup and crown for tooth #12 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve core buildup and crown for tooth #12. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an accessory bag with embroidery and a cup holder 
(K0108). 
 
You asked the Plan to pre-approve a wheelchair component or accessory. You say that you are always falling 
and getting injured. The Plan denied your request. The Plan says your request is not a covered benefit because 
an accessory bag with embroidery and a cup holder do not primarily serve a medical purpose and are not 
medically necessary. 
 
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 an accessory bag with embroidery and a cup holder 
(K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for all 
four quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scalings and root planings (D4341) for all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning (D1110) and recement crown (D2920) provided 
on February 16, 2022 by an out of network (OON) dentist. 
 
You asked the Plan to pay for the dental services. You say that you did not receive a cleaning as your crown 
was damaged in the process. You say that there are no in network providers in your area. You also say that you 
should not be responsible for this bill. The Plan denied your request. The Plan says dental services that you 
receive out of network are not covered. The Plan also says that recement crown is not listed as a covered 
service. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the dental services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the cleaning (D1110) and recement crown (D2920) provided on February 16, 
2022 by an out of network (OON) dentist.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 7, 
2021, to June 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider is ineligible. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
You are not eligible to bill Medicare. The Plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these items/services. 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 home health services provided to the enrollee from April 7, 2021, to June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on April 3, 2021, to 
April 12, 2021. 
 
You asked the Plan to pay for critical care. You say that the medical records have been sent, and these services 
are supported in the record. The Plan denied your request. The Plan says these services are not supported in the 
record. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the critical care services at 
issue were billed with a time-based code, but the time spent providing these services is not noted in the medical 
records. Based on this information, we decided that Medicare rules for coverage of critical care have not been 
met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided on 
April 3, 2021, to April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for inpatient admission for knee replacement.
You asked the Plan to provide coverage for inpatient admission. You say that inpatient admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says inpatient admission is not required for
this procedure. 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 inpatient
admission for knee replacement surgery. The Maximus Physician Reviewer determined that the documentation
supported that the criteria for an inpatient hospital admission were met in this case. The Plan requested a
reopen and argues that at the time of the pre-service review, the enrollee's comorbidities were not exacerbating.
The Plan argues that without a medical predictability for an adverse event before the planned surgery, or
without a concurrent acute adverse event perioperatively, prior authorization approval would not be appropriate
before the surgery occurred.
The medical records show the enrollee was a then 82-year-old man with a medical history notable for
hypertension, kidney disease, cardiac murmur, back instability, and monoclonal gammopathy. Knee
replacement surgery was planned. The plan is correct in this case. The documentation does not sufficiently
support that at the time of inpatient admission, it was reasonable for the admitting physician to expect that the
enrollee's necessary hospital care would span two midnights. Inpatient 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 inpatient admission have not been met. Therefore, we decided that the Plan does
not have to provide coverage for inpatient admission for knee replacement for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The patient has right 
shoulder pain related to osteoarthritis. A right shoulder arthroplasty procedure was approved, and inpatient 
services were requested for this procedure. This planned surgery is lower risk. The patient passed medical 
clearance, according to the records, and did not have any unstable medical conditions that might suggest the 
patient would require hospital services related to this procedure. The records did not show that the patient 
would require hospital services that would likely cross 2 midnights. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 2. 
 
You asked the Plan to pre-approve a crown. You say that your crown fell off and you feel the Plan should 
cover having it replaced. The Plan denied your request. The Plan says you will exceed the frequency limit for 
this service. 
 
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 a crown once 
per tooth every five years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a crown for tooth 2 
was previously covered on September 24, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of a crown for tooth 2 will be exceeded with the requested service. Therefore, we 
decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on September 8, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
coded appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic panel testing provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant placement (D6010) for tooth #5. 
 
You asked the Plan to pre-approve a dental implant. You say that this service is necessary. The Plan denied 
your request. The Plan says dental implants are not covered by your dental 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 pre-approve a 
dental implant placement (D6010) for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - periapical each additional radiographic image (D0230) provided December 7, 
2021. 
 
You asked the Plan to pay for the comprehensive oral exam and additional periapical x-ray. You say that as far 
as you were told all your services would be covered. The Plan denied your request. The Plan says you have 
exceeded the frequency limits for these services. 
 
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 
comprehensive oral exam once every three years and a periapical x-ray once per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on December 6, 2019, and one periapical x-ray was covered on December 7, 
2021. Based on this information, we decided that the Plan's frequency limits for coverage of the comprehensive 
oral exam and periapical x-ray have been exceeded. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - periapical each 
additional radiographic image (D0230) provided December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that this is necessary. The Plan denied your 
request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
September 15, 2021, to November 3, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on September 15, 2021, to November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2331 x 2, D2392), oral exam (D0120), 
periodontal maintenance (D4910), and bitewing x-rays (D0274) provided from January 6, 2022, to January 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist really cares about their patients. 
You say that you have had bad experiences at the dentist in the past. You also say that you would like at least 
some of this bill to be covered. The Plan denied your request. The Plan says dental services received out of 
network are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
fillings (D2331 x 2, D2392), oral exam (D0120), periodontal maintenance (D4910), and bitewing x-rays 
(D0274) provided from January 6, 2022, to January13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg with advanced foot system.
You asked the Plan to provide coverage for an advanced foot system. You say that the advanced foot system is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 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 an adjustable
volume socket. The Maximus Physician Reviewer determined the adjustable volume socket was medically
necessary and reasonable. The Plan requested a reopen and stated that the requested adjustable volume socket
does not have FDA approval and is experimental. The medical records show you are a 42-year-old woman with
bilateral lower extremity amputations. The medical records do not support that the adjustable volume socket
would be more beneficial than the existing and medically appropriate standard accessory. 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 prosthetic accessory are not met. Therefore, we decided that the Plan does not have to provide
coverage for a prosthetic leg with advanced foot system.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay this claim as billed.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan provided documentation to show the
provider billed and was paid for one unit of 43246-AS. The denied code of 43246-AS-59 exceeded the
allowable unit of 1 per Medicare MCR MUE Practitioner Services. Per NCCI Chapter, Section V: MUEs for
HCPCS codes with an MAI of "2" are absolute date of service edits.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the claim
records provided by the Plan show these services were already paid. Therefore, we decided that the Plan does
not have to pay for to pay for surgery services provided to the enrollee on August 31, 2021 and billed under
code 43246.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for teeth #23 through #26. 
 
You asked the Plan to pre-approve the crowns. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of medical or dental necessity. 
 
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 crowns 
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 crowns. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found the 
documentation provided was not sufficient to determine if there was sufficient coronal breakdown requiring the 
need for crown restorations. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns for teeth #23 through #26.