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

We decided the Plan does not have to provide coverage for SBRT for the enrollee.
You asked the Plan to provide coverage for SBRT. You say that this treatment 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 coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Stereotactic Body
Radiation Therapy (SBRT). The Maximus Physician Reviewer determined that the treatment offered to this
enrollee, SBRT to sites of oligoprogression including nodal sites, could be furnished in accordance with
accepted standards, acknowledging that the data supporting this treatment continue to arise. The Plan requested
a reopen and argued the enrollee has 3 sites of disease, the RLL lung nodule and two lymph nodes:
supraclavicular and hilar. The Plan states that their denial was appropriately in line with the LCD and NCCN
guidelines as the enrollee has not had previous radiation therapy to any of these areas, so SBRT is not
supported based on retreatment.
Our Medical Director has concluded that the Plan is correct in this case. The records show the enrollee is a 69-
year-old woman with stage IV non-small cell lung cancer (adenocarcinoma). The enrollee has been treated with
pembrolizumab. The Medicare LCD L35076 states that SBRT treatment of any body site or internal organ, is
indicated for treatment of recurrence in or near previously irradiated regions when a high level of precision and
accuracy or a high dose per fraction is indicated to minimize the risk of injury to surrounding normal tissues
and treatment with conventional methods is not appropriate or safe for the particular patient. The LCD further
states that SBRT is not considered medically necessary under the following circumstances for any condition:
Recurrent (other than pelvic and head and neck tumors) or metastatic disease could be treated by conventional
methods (record must describe why other radiation therapy measures are not appropriate or safe for the
particular patient). The clinical documentation does not describe why other radiation therapy measures are not
appropriate or safe for the enrollee in this case. Medicare coverage criteria are 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Stereotactic Body Radiation Therapy (SBRT) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (dental code D0140) and an intraoral - 
periapical first radiographic image (dental code D0220) for tooth #1 through #32 provided on February 17, 2022. 
 
You asked the Plan to pay for an oral evaluation and an intraoral - periapical first radiographic image. You say 
that you had coverage for dental exam and x-rays and the claim should not be denied. The Plan denied your 
request. The Plan says these services are not covered by the Plan's dental benefits. 
 
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 an oral 
evaluation (dental code D0140) and an intraoral - periapical first radiographic image (dental code D0220) for 
tooth #1 through #32 provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower partial dentures (D5213, D5214). 
 
You asked the Plan to pre-approve upper and lower partial dentures. You say that the enrollee is not able to 
wear her current dentures. The Plan denied your request. The Plan says this request exceeds the frequency 
limitation. 
 
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, it covers only 1 upper and 1 lower 
partial denture every 5 years. The record shows that the enrollee last received upper and lower partial dentures 
in November of 2020. Therefore, we decided that the Plan does not have to pre-approve upper and lower partial 
dentures (D5213, D5214).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies 
(95909) and neuromuscular junction testing (95937) provided on December 1, 2021. 
 
You asked the Plan to pay for testing services. You say that these services are supported as billed. The Plan 
denied your request. The Plan says these services are not supported in the medical 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. In this case, the CPT Code Manual definition of 
code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure), and the definition of code 95909 is nerve 
conduction studies; 5-6 studies. 
 
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 testing services. Our reviewer says that these services are 
not supported as billed. Our reviewer found that neuromuscular junction testing is an inappropriate code to report 
for the service provided in this case, which is Train of Four (TOF) testing. No code exists for TOF testing, as it 
is inclusive to the intraoperative neuromonitoring procedure code which was previously approved by the Plan. 
The services which were billed as nerve conduction studies are better described as, "pedicle screw stimulation". 
It is inappropriate to report service provided as nerve conduction studies, and therefore this procedure code 
cannot be verified, as performed. In addition, the needle electromyography (95885) cannot be verified as this 
code requires the service be done with nerve conduction studies. Therefore, these services are not supported as 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing services have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography (95885), nerve conduction studies (95909) and neuromuscular 
junction testing (95937) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 4, 18, 19, and 30 and core 
buildups, including any pins when required (D2950) for tooth #'s 4, 18, 19, and 30. 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that you need the partials and 
crowns due to the issues you are having with your teeth rotting, and with the teeth in back being pulled there 
will be a gap. The Plan denied your request. The Plan says tooth #18 and tooth #19 exceed the benefit 
limitation for crowns which are covered once per tooth every 60 months. The Plan also says that insufficient 
bone support does not meet medical criteria for buildups and crowns. 
 
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 crowns and 
core buildups 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 and core buildups. Our 
reviewer says that the crowns for tooth #'s 4 and 30 and core buildups for tooth #'s 4 and 30 are not medically 
necessary. Our physician reviewer found the teeth in question have been previously crowned as ween in the 
radiographs. There are no clear defects around the existing crowns on tooth #s 4 or 30 and no documentation 
to indicate a rationale for replacement. Core buildups are only necessary when a crown is to be placed, and 
only where there is insufficient structure to retain a new crown. Our reviewer found that in this instance, there 
has been no clear showing of a need for replacement of tooth #'s 4 or 30, though a clinical narrative could 
clarify the situation if there is something of importance not seen on the x-ray views.  Our physician reviewer 
also found that given the documentation presented there is no necessity for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. The contract clearly states that crown 
(D2740 or D2752) and core buildup, including any pins when required (D2950) are covered benefits, and are 
each limited to once per 60 months on the same tooth. The record shows that you received a crown (D2752) 
and core buildup (D2950) on tooth #18 on March 6, 2018, and you received a crown (D2752) and core buildup 
(D2950) on tooth #19 on December 4, 2018, and your crown and core buildup benefits for tooth #s 18 and 19 
have been exhausted. Based on this information, we decided that the Plan's rules for coverage of the crowns 
and core buildups have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns 
(D2740) for tooth #'s 4, 18, 19, and 30 and core buildups, including any pins when required (D2950) for tooth 
#'s 4, 18, 19, and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (dental code D0120) and 
prophylaxis - adult (dental code D1110) for tooth #1 and #32 provided on November 11, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis - adult. You say that you are 
requesting to have your teeth cleaned and examined every 3 months. The Plan denied your request. The Plan 
says the denial of payment for both services is correct, because 2 examination's and 2 prophylaxis - adult are 
covered per plan year and you previously received both services on April 14, 2021, and July 27, 2021. 
 
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 2 exams and 
2 prophylaxis - adult per plan year. 
 
We looked at the file, the Plan's rules, and Medicare rules. You previously received 2 covered exams and 2 
prophylaxis - adult on April 14, 2021, and July 27, 2021; therefore, the benefit was exhausted for date of 
service November 11, 2021. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (dental code D0120) and prophylaxis - adult (dental code D1110) for tooth #1 and #32 provided on 
November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical connection between power systems (E2311). 
 
You asked the Plan to pre-approve electrical connection. You say that this device is medically necessary for the 
enrollee's use of the power wheelchair. The Plan denied your request. The Plan says the criteria for coverage 
have not been met for the requested equipment. 
 
The Plan follows Medicare rules. Medicare rules say that the electric connection between power systems is 
subject to the criteria listed in the Medicare rules. 
 
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 electrical connection. Our reviewer says that the requested electric connection between power systems is not medically reasonable and necessary. Our 
physician reviewer found that based on the medical records provided there is no documentation that it is 
medically necessary (as defined by Medicare criteria) to control the power wheelchair's power options through 
a joystick. Provided records document that you have 4/5 bilateral upper extremity strength, and you are 
modified independent with your activities of daily living thus indicating you have adequate upper extremity 
strength and function to operate the wheelchairs power options with your own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrical connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electrical connection between power systems (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions and alveoplasty services provided by a 
participating provider on February 9, 2022. 
 
You asked the Plan to pay for dental extractions and alveoplasty services. You say that you felt like the Plan 
should pay for more. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 dental 
extractions with a 50% coinsurance. The Plan does not cover alveoplasty services. 
 
We looked at the file and Medicare rules. The correct coinsurance has been applied to the extractions that were 
rendered. Based on this information, we decided that the Plan's rules for coverage of dental extractions have 
been processed correctly. The Plan does not cover alveoplasty services. Therefore, we decided that the Plan 
does not have to pay for dental extractions and alveoplasty services provided by a participating provider on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up and porcelain crown (D2950, D2740) 
for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that there are several cracks in the teeth. The 
Plan denied your request. The Plan says the documentation includes states that there are cracks; however, the x-
rays submitted do not clearly show this. 
 
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 dental 
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 to pre-approve the dental services. Our reviewer says 
that the requested services are not medically reasonable or necessary. Our physician reviewer found the teeth 
were noted as having cracks present that were anticipated to cause pulpal involvement over time. The copied x-
rays and photos did not appear to show significant cracks in the teeth. Superficial cracks in the enamel are not 
uncommon in teeth and rarely progress to significant fractures of the teeth. The plan provides that " Onlays and 
crowns are payable only when necessary due to decay or tooth fracture. However, if the tooth can be 
adequately restored with another material such as amalgam, payment will be made for that procedure. 
This payment can be applied towards the cost of the onlay or crown. This provision only applies when the 
restorative procedure provided is due to decay or tooth fracture. If the procedure is provided for some other 
purpose, e.g., esthetics, an alternative procedure such as an amalgam or composite restoration is not eligible for 
payment." In this instance the teeth in question appear to be restorable with conventional materials, and can not 
be seen to definitively require any restoration at this time.  Given the provided materials and the plan 
provisions, it does not appear that the crowns meet the criteria for full coverage 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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a core build-up and porcelain crown (D2950, D2740) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) provided on February 21, 2022. 
 
You asked the Plan to pay more for the comprehensive oral evaluation and panoramic x-ray. You say that you 
feel you should not have to pay for a service that has caused you pain and issues. The Plan denied your request. 
The Plan says you pay a $7.50 copayment for exams from an in-network provider. The Plan also says that you 
pay a $15 copayment for x-rays from an in-network provider. 
 
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, you are responsible for a $7.50 
copayment for the comprehensive oral evaluation, and a $15 copayment for the panoramic x-ray. Therefore, we 
decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on February 21, 2022.  
 
Your complaint about the treatment you received leaving you in pain is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D220, D0230) or waive the cost share for a 
crown (D2752) provided on December 16, 2021. 
 You asked the Plan to pay for x-rays and crown. You say that you were told that crowns were covered at 100%. 
The Plan denied your request. The Plan says a periapical x-ray is a covered service by the Plan's dental 
benefits; however, your benefit for one procedure in the intraoral group per calendar year has been exhausted. 
The Plan also says that you have been charged the correct cost sharing for a crown. 
 
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 one procedure 
in the intraoral x-ray group per calendar year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
periapical x-ray provided on February 5, 2021; therefore, the benefit for a periapical x-ray has been exhausted. 
Therefore, we decided that the Plan does not have to pay for periapical x-rays (D220, D0230) provided on 
December 16, 2021.  
 
You have been asked to pay $693.70, which is 70% coinsurance of the allowed amount for a crown ($991 
allowed amount x 70% coinsurance = $693.70). A crown falls within the Dental 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 waive the cost share for a crown (D2752) provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292, 81301) provided 
on September 15, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292, 81301) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parenteral drugs (D9612) provided on February 8, 2022. 
 
You asked the Plan to pay for parenteral drugs. You say that you needed to be sedated to have your tooth 
extracted. The Plan denied your request. The Plan says therapeutic parenteral drugs (D9612) are not covered by 
your routine dental benefits. 
 
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 
therapeutic parenteral drugs (D9612) provided on February 8, 2022.