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

 
We decided that the Plan has to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says that the service is not medically necessary. 
 
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 
Plans rules apply in this case. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of acupuncture services have been met. Specifically, there is no indication the enrollee's supplemental 
benefit for acupuncture has been utilized. Therefore, we decided that the Plan has to pre-approve acupuncture 
services.  
 
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 lab services provided to the enrollee on December 6, 2021.
You asked the Plan to pay for these lab services. The Plan denied your request. The Plan says the Medicare billing 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 notes the claim was billed with a place of service (POS) 81, defined as a lab independent of an institution or physician's office. This code would be billed if the sample was taken directly by the independent lab. The records show the specimen was collected at the hospital not by the independent lab.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim was submitted with the incorrect POS code. Medicare rules for coverage of these services were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 26, 2021.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial for medical necessity. The Plan requested a reopen and stated testing for the FANCC and BLM genes is
not a Medicare benefit and is statutorily excluded service. In addition, the claim did not include the required
DEX Z Code or unique test identifier code required by Medicare.
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 code. In this case, this claim was
not submitted with the required test identifier code and the medical records do not establish these services were
covered by Medicare. Medicare rules for coverage of this testing have not been met. Therefore, we decided that
the Plan does not have to pay for genetic testing provided to the enrollee on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests (CPT code K0195), standard 
wheelchair (K0001) and manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 
20 inches and less than 24 inches (E2201). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 DME. Our physician reviewer 
found the documentation available for review does not indicate the enrollee has a medical condition that would 
necessitate elevating leg rests or a nonstandard seat frame or width for the authorized wheelchair. 
 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve elevating leg rests (CPT code K0195), standard wheelchair (K0001) and manual wheelchair 
accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches (E2201).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the COVID-19 testing kits purchased on January 26, 2022.
You asked the Plan to reimburse you for the COVID-19 testing kits. You say that you want to appeal the amount being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged is correct.
The Plan must follow Medicare rules. The rules say that plans were given the option to cover COVID-19 home testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan communicated to enrollees that this testing would be covered as a supplemental benefit, free of charge, after February 1, 2022, unless the testing was required prior to that date due to physician intervention. The medical records do not show you saw your physician on January 26, 2022. Furthermore, Medicare did not cover purchased or over the counter COVID-19 home testing kits until April 4, 2022. Your purchase was made prior to both dates without physician intervention. Therefore, we decided that the Plan does not have to reimburse you for the COVID-19 testing kits purchased on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on April 4, 2022. 
 
You asked the Plan to pay for an occlusal guard (D9944). You say that you were diagnosed with a very painful 
case of temporomandibular joint (TMJ), which caused headaches and occasional locking of your jaw. You also 
say the dentist recommended this appliance to replace the one you had been using. The Plan denied your 
request. The Plan says an occlusal guard (D9944) is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 2022.
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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the errors on the claim and the omission of required codes. The Plan states the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on December 10, 2021. The specimen was received on March 2, 2022. There is no documentation of molecular pathology testing performed on March 9, 2022. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Additionally, the claim did not include the required DEX Z-Code or unique test identifier code.
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, this claim was not pad due to issue with the dates of service versus the dates the specimen was collected, the report POS code and the omission of the unique test identifier code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive electrophysiologic evaluation services 
(93656) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a comprehensive electrophysiologic evaluation. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage of OON services have not been met. 
 
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 
comprehensive electrophysiologic evaluation services (93656) to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy provided on June 28, 2022. 
 
You asked the Plan to reduce the copayment for an endoscopy. You say that you were told your copayment 
would be lower. 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 $375 
copayment for outpatient hospital services (including diagnostic colonoscopy, excluding certain wound care 
services). 
 
You have been asked to pay a $375 copayment for an endoscopy. This item/service falls within the outpatient 
hospital services (including diagnostic colonoscopy, excluding certain wound care services) 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 reduce the copayment for an endoscopy provided on June 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Sildenafil tablet. 
 
You asked the Plan to pre-approve Sildenafil. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Sildenafil 
tablet.  
 Benefits for Sildenafil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (A0100) to an animal 
hospital. 
 
You asked the Plan to pre-approve non-emergency transportation (A0100) to an animal hospital. You say that 
as a heart transplant recipient, you were under exercise therapy daily and the Plan set up rides back and forth to 
therapy post-transplant. You also say that you called the Plan and they stated that volunteer services are okay 
for ride assistance, and now it has been denied. The Plan denied your request. The Plan says your Plan's benefit 
allows for routine non-emergency visits to plan approved locations such as a doctor's office. The Plan also says 
that the request for a transportation trip to an animal hospital is not covered as it is not a plan approved 
location. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when The Plan rules say that customers are required to contact the Plan's transportation vendor at least 48 hours in advance of their appointment to schedule non-emergent 
transportation services to plan-approved locations, such as doctors appointments. Animal hospitals are not 
plan-approved locations.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation (A0100) to an animal hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device/appliance (E0485) at an in-network rate. 
 
You asked the Plan to pre-approve an oral device/appliance (E0485) at an in-network rate. You say that this 
oral device is critical to your sleep apnea treatment. The Plan denied your request. The Plan says this provider 
of the oral appliance (E0485) is an out-of-network provider, so in-network coverage is denied. 
 
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 an oral 
device/appliance (E0485) at an in-network rate when the services are medically necessary and reasonable.  
 
 
  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an oral device/appliance (E0485) at an in-network rate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an oral device/appliance (E0485) at an in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate sedation (D9243) provided on July 
18, 2022. 
 
You asked the Plan to pay for the intravenous moderate sedation (D9243). You say that you were told that this 
would be covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intravenous moderate sedation 
(D9243) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the intravenous moderate sedation (D9243) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on September 
20, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the x-rays were denied for no reason and should be 
covered. The Plan denied your request. The Plan says periapical x-rays (D0220, D0230) are not covered by 
your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periapical 
x-rays (D0220, D0230) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on September 06, 2022. 
 
You asked the Plan to pay for the transcutaneous electrical nerve stimulation (TENS) device. You say that your 
PCP felt this device was 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 the transcutaneous 
electrical nerve stimulation (TENS) device provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollees PCP sent them to this provider. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 the office visit provided 
on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation provided on August 9, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you did not have more than two oral 
exams in 2022. 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 dates of service January 24, 2022, and 
April 21, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronectomy (D7251) and therapeutic parenteral drug 
(D9610). 
 
You asked the Plan to pre-approve a coronectomy and therapeutic parenteral drug. You say that you will not be 
able to get dentures without these services being provided. The Plan denied your request. The Plan says these 
services are not covered under your benefit package. 
 
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 
coronectomy (D7251) and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic tooth #4 (D2740), core buildup, 
including any pins when required tooth #4 (D2950), and localized delivery of antimicrobial agents via a 
controlled release vehicle (D4381 x2) provided on January 6, 2022, and March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel that the dental office is over charging 
you for what your dental plan should have covered. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown - 
porcelain/ceramic tooth #4 (D2740), core buildup, including any pins when required tooth #4 (D2950), and 
localized delivery of antimicrobial agents via a controlled release vehicle (D4381 x2) provided on January 6, 
2022, and March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on September 30, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you do not think you should have to pay for 
something so simple in order to detect glaucoma. The Plan denied your request. The Plan says this service is 
not a covered benefit since it was performed with a medical diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions when they are performed during a routine screening. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were seen for a diagnosis of 
Dermatochalasis of right upper eyelid, Dry eye syndrome of bilateral lacrimal glands, and Vitreous 
degeneration, bilateral. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
provided on September 30, 2022.