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

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a comprehensive periodontal 
evaluation (D0180), and a limited oral evaluation (D0140) provided on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the provider has opted out of Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Based on the information the Plan provided we are unable to verify if the 
provider has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for prophylaxis 
(D1110), a comprehensive periodontal evaluation (D0180), and a limited oral evaluation (D0140) provided on 
October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crowns (D6058) 
provided on March 10, 2022. 
 
You asked the Plan to pay for the abutment supported porcelain/ceramic crowns. You say that the Plan pays 50 
percent for porcelain crowns. You also say that you feel reimbursement to the doctor in the amount of 
$1,325.00 is feasible in your case. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental 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 pay for the 
abutment supported porcelain/ceramic crowns (D6058) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the complete series of x-rays. We decided that the Plan does not have 
to pay for the comprehensive oral exam.  
 You asked the Plan to pay for the complete series of x-rays. You say that your records show no treatment for 
this service in the previous six-month period. The Plan says that you have exceeded the frequency limits for 
these services. 
 
We decided that the Plan has to pay for the complete series of x-rays.  
 
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 contract says that the 
Plan covers one full mouth/panoramic x-ray every three years. 
 
In this case the Plan has failed to provide documentation showing that another full mouth or panoramic x-ray 
has been covered in the past three years. Thus, the enrollee appears to meet the Plans frequency criteria for 
coverage of the complete series of x-rays. Therefore, we decided that the Plan has to pay for the complete 
series of x-rays.  
 
We also decided that the Plan does not have to pay for the comprehensive oral exam. 
 
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 contracts say that the 
Plan covers one oral exam every six months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan 
provided documentation showing that an oral exam was previously covered on March 14, 2022. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral exam. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (CPT code 64454). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the service is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting 
of knee osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) is still under 
investigation and is considered experimental. Therefore, the request is considered not medically reasonable or 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block (CPT code 64454).
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 prophylaxis - adult (D1110) provided July 29, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and dental cleaning. You say that you were not 
informed that the provider had opted out of Medicare. The Plan denied your request. The Plan says these 
services are not covered because the provider has opted out of Medicare. 
 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 and dental cleaning when you see any licensed dental provider who accepts Medicare 
patients in the United States and has not opted out of Original Medicare  
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the comprehensive oral exam and dental cleaning have not been 
met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) and prophylaxis - adult (D1110) provided July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and to adjust 
mandibular complete denture (D5411), and to pay for oral hygiene instructions (D1330) and unspecified 
preventive procedure (D1999) provided on April 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you called the insurance company before 
your appointment and were told the services would be covered at 100%. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The Plan also says that oral hygiene instructions 
(D1330) and unspecified preventive procedures (D1999) 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Oral 
hygiene instructions (D1330) and unspecified preventive procedures (D1999) are not covered under this 
benefit. Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation 
(D0150) and to adjust mandibular complete denture (D5411), and to pay for oral hygiene instructions (D1330) 
and unspecified preventive procedure (D1999) provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 26, 2021 billed with 
codes 81206, 81275, 81276, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 26, 2021 billed with codes 81206, 81275, 81276, and 81301.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested bone marrow aspirate 
remains experimental in nature, as more research is needed to show its safety and efficacy when used as bone 
graft material. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided by a network provider 
on February 10, 2022. 
 
You asked the Plan to pay for the occlusal guard (D9944). You say that the service is not covered under the 
dental plan, but it should be covered under the medical side of the plan. You say your jaw was not aligning and 
activating your temporal-mandibular joint (TMJ) pain. The Plan denied your request. The Plan says the service 
is not a covered benefit and is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the occlusal guard (D9944). Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that the documentation shows 
the occlusal guard is not appropriate for TMJ treatment. The record indicates that the occlusal guard is for a 
teeth-grinding condition, which is dental in nature.  
 
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 occlusal guard (D9944) have not been met. Therefore, we decided that the 
Plan does not have to pay for the occlusal guard (D9944) provided by a network provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for anatomical crown exposure (code D4231) and 
periodontal scaling and root planing (code D4342) provided on March 30, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services are needed to preserve and 
prevent loss of your teeth. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The Plan also says anatomical crown exposure is not a covered supplemental 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, anatomical crown exposure (D4231) is 
not among those covered under this benefit. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the scaling and planing. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for anatomical crown 
exposure (code D4231) and periodontal scaling and root planing (code D4342) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of mechanical traction (code 97012). 
 
You asked the Plan to pay for the mechanical traction. You say that according to your enrollment guide 
chiropractic services are covered. The Plan denied your request. The Plan says the mechanical traction is not a 
covered service when obtained from a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the application of mechanical traction (code 97012).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two (2) additional units of ingestion challenge tests (95079) 
billed for January 17, 2022. 
 
You asked the Plan to pay for additional units of code 95079. You say that these services were medically 
necessary and are supported in the medical record; the enrollee received a total of 360 minutes of ingestion 
challenge testing. The Plan denied your request. The Plan says they have agreed to pay for 2 units of this 
service, however the additional 2 units billed exceeds the MUE for this service. 
 
The Plan must follow Medicare Rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. The rules also say that services with an MAI of 3 are per day edits based 
on clinical benchmarks. It is possible, but medically highly unlikely that higher MUE values would represent 
correctly reported, medically necessary services. If contractors have evidence that the UOS in excess of the 
MUE value were actually provided, were correctly coded and were medically necessary, the contractor may 
bypass the edit. 
 
In this case, the MUE for CPT code 95079 is 2. The MAI value for this code is 3. The provider billed 4 units of 
this service, exceeding the MUE by 2. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for additional units of code 95079. Our reviewer 
says that bypassing the MUE edit is not supported in this case. Our physician reviewer found that although the 
medical records do support that four units of 95079 were provided on the date in question, the records do not 
support that the additional two units were medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional units of code 95079 have not been met. Therefore, we decided that 
the Plan does not have to pay for two (2) additional units of ingestion challenge tests (95079) billed for January 
17, 2022.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerecis Omega 3 skin substitute for the enrollee.
You asked the Plan to pre-approve the requested skin substitute. 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
criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Kerecis Omega3
skin substitute. The Maximus Physician Reviewer determined that the enrollee had a full thickness skin loss
ulcer that is the result of abscess, injury or trauma that had failed to respond to appropriate control of infection,
foreign body, tumor resection, or other disease process for a period of 4 weeks or longer. It was decided that
the Medicare rules for coverage of the Kerecis Omega3 skin substitute were met.
The Plan states it disagrees with our consultant's determination. The Plan states that the lesion in question was
not a non-healing wound due to diabetic neuropathy, venous stasis, or injury/trauma as defined by the LCD, but
rather a cancerous lesion for which application of any form of skin substitute would have been unlikely to help.
The medical records show the enrollee is an 86-year-old woman with well-differentiated squamous cell
carcinoma on her left ankle. The records state "Due to the size of the lesion expected post-Mohs surgery our
providers are recommending the use of Kerecis Omega3 skin substitute to promote wound healing." The Plan's
reasoning is not entirely correct in this case. However, the documentation does not support that the enrollee had
a wound that had failed to respond to standard wound care treatment of greater that 4 weeks, nor were specific
interventions that had failed referenced. Rather, the documentation suggests that the Kerecis Omega3 skin
substitute was being ordered pre-operatively in anticipation of an operative wound. The coverage criteria as
established by the LCD were not met in this case.
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 requested skin substitute have not been met. Therefore, we decided that the
Plan does not have to pre-approve Kerecis Omega 3 skin substitute for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a dental crown (D2740).
You asked the Plan to provide coverage for these dental services. You say that this crown should be covered by
the Plan. The Plan denied your request. The Plan says this service has coverage limitations. The records show
you had this service on December 22, 2021. Therefore, this benefit was not when requested in March 2022.
Maximus overturned the Plans denial for lack of claim information in the file to confirm the December service.
The Plan requested a reopen and provided the required claim information.
The Plan is correct in this case. Medicare does not cover dental services. 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 more than Medicare coverage, this service was not available for coverage when service
was requested. Therefore, we decided the Plan does not have to provide coverage for a dental crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 8, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 8, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), a periodic oral evaluation 
(D0120), periapical x-ray (D0220), additional periapical x-rays (D0230 x 3), and application of fluoride varnish 
(D1206) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was the only time you have seen the 
provider and it is not clear as to what previous claim the insurance is referring too. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910), a periodic oral evaluation (D0120), periapical x-ray (D0220), additional periapical x-rays (D0230 x 3), and application of 
fluoride varnish (D1206) provided on March 22, 2022.