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

We decided that the Plan does not have to pre-approve endosteal implant on tooth #14 (D6010), prefabricated abutment on tooth #14 (D6056), and implant supported crown on tooth #14 (D6066).
You asked the Plan to pre-approve an implant, abutment, and crown. You say that your doctor recommended these services. You also say that you are in pain and food is constantly getting stuck. The Plan denied your request. The Plan says these services are not covered by your 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 pre-approve endosteal implant on tooth #14 (D6010), prefabricated abutment on tooth #14 (D6056), and implant supported crown on tooth #14 (D6066).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 6, 2021.
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 medical necessity was not established. Maximus overturned the Plans denial for
insufficient denial explanation in the case file. The Plan requested a reopen and provided additional
information regarding the denial.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. There were insufficient medical records submitted to
show this testing was medically necessary. 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 August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implant parts and maintenance. 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says that your request has been denied due to a lack 
of a physicians order and supporting medical records. 
 
The Plan must follow Medicare rules. The rules say that all claims for Durable Medical Equipment, Prosthetic, 
and Orthotic Supplies (DMEPOS) require a written order/prescription from the treating practitioner. The rules 
also say for Medicare to consider coverage and payment for any item or service, the information submitted by 
the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. 
 
The Plan made multiple requests for a written order from the provider for the requested items and none was 
submitted. In addition, the medical record of the visit on May 4, 2022, makes no reference to a need for these 
supplies as the note documents that the cochlear implant was in good working order at that time.   
Additional information from the treating physician, including a written order and/or documents supporting the 
medical necessity of the requested items, is required to allow coverage in this case. Therefore, we decided that 
the Plan does not have to pre-approve cochlear implant parts and maintenance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office consultation (99244) provided on November 10, 
2021. 
 
You asked the Plan to pay for the office consultation (99244). You say that the claim should be reconsidered 
with the attached medical records and reprocessed for payment. The Plan denied your request. The Plan says 
the code billed is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that CPT code 99244 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the office consultation (99244) have not been met. Therefore, we decided that the Plan does not 
have to pay for the office consultation (99244) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) (22514). 
 
You asked the Plan to pre-approve a percutaneous vertebral augmentation. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure does 
not meet criteria. 
 
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 a percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records show the bone retropulsed into the spinal canal. This is a 
contraindication to cement augmentation procedures. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care provided outside the dentists office (D9420) 
 
You asked the Plan to pre-approve the care provided outside the dentists office. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within the enrollees 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 pre-approve care 
provided outside the dentists office (D9420)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a post and core (D2952) provided 
by a participating provider. 
 
You asked the Plan to pre-approve a crown and a post and core. You say that this is to replace your cracked 
crown. The Plan denied your request. The Plan says the benefit limit for D2740 has already been met and 
exhausted. The Plan says that D2952 is not a covered 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. The Plan covers a crown once 
every five years per tooth. The Plan does not cover a post and core. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. D2952 is not a covered dental benefit. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740) and a post and core (D2952) provided by a participating 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control for the enrollee. 
 
You asked the Plan to pre-approve an attendant control. You say that this is medically necessary. The Plan 
denied your request. The Plan says that an attendant control cannot be covered if a user-operated control is 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a 
beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the enrollee-
operated device control system provided with the already approved power wheelchair. Based on this 
information, we decided that Medicare rules for coverage of an attendant control have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an attendant control for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) provided on 
March 1, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency 
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 Plan's coverage rules apply in this case. The Plan covers dental exams 
once every three calendar years.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract states that dental exams are covered 
once every three calendar years. You received a comprehensive oral evaluation previously on August 30, 2021 
that was paid for by the Plan; therefore, you have exceeded the allowable benefit for this service.  Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral examination (D0150) 
provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heel height adjustment feature (L5990) and a 
protective outer covering (L5964). 
 
You asked the Plan to pre-approve the heel height adjustment feature and protective outer covering. You say 
that it is felt this should be approved as requested. The Plan denied your request. The Plan says all other 
requested items were approved except for the noncovered heel adjustment feature and the outer covering which 
is not shown to be medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that heel adjustment features are noncovered as they are 
not medically necessary. In addition, protective outer surface covering systems (L5962, L5964, and L5966) are 
specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has 
special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by standard coverings. 
 
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 heel height adjustment feature and 
protective outer covering. Our reviewer says that the records do not support the medical necessity of the 
requested protective covering. Our physician reviewer found the documentation does not support an 
extenuating circumstance or environment that would necessitate a protective outer surface for the prosthesis. 
 
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 heel height adjustment feature and protective outer covering have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a heel height adjustment feature (L5990) 
and a protective outer covering (L5964).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #21, 28, 29, 30, and 31 
(D6010). 
 
You asked the Plan to pre-approve implants. You say that you are in a lot of pain and now have an infected 
tooth. The Plan denied your request. The Plan says endosteal implants are not covered by your 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 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 
endosteal implants on tooth #21, 28, 29, 30, and 31 (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81275, 81276, and 
81301 provided on June 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 81206, 81275, 81276, and 81301 are not supported in the medical record. Specifically, 
when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Review of the file does not support that only one code was billed for the panel 
provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81206, 81275, 81276, and 81301 provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial dentures (D5214). 
 
You asked the Plan to pre-approve dentures. You say that you accidentally threw out your dentures. The Plan 
denied your request. The Plan says this service is covered by your Plan's dental benefits; however, your benefit 
for one mandibular partial denture every five years has 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. The Plan covers one 
mandibular partial denture (D5214) every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
mandibular partial denture provided on July 18, 2019; therefore, the benefit for one mandibular partial denture 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve mandibular partial 
dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that without the bone replacement 
graft, dental implant placement would be challenging The Plan denied your request. The Plan says bone 
replacement graft is not covered under the enrollee's supplemental 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 pre-approve the 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0367) and a limited oral evaluation 
(D0140) provided on February 24, 2022. 
 
You asked the Plan to pay for imaging and an evaluation. You say that you went to your dentist about a 
suspicious lesion and were referred to an oral surgeon. The Plan denied your request. The Plan says cone beam 
imaging (D0367) and a limited oral evaluation (D0140) are not covered by your 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 cone 
beam imaging (D0367) and a limited oral evaluation (D0140) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (porcelain laminate) (D2962) for tooth #9. 
 
You asked the Plan to pre-approve a labial veneer. You say that this service is necessary. The Plan denied your 
request. The Plan says this service is 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 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 pre-approve a 
labial veneer (porcelain laminate) (D2962) for tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impacted tooth removal (D7220) provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve an impacted tooth removal. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested dental work 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 pre-approve an 
impacted tooth removal (D7220) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain crown on tooth #21 (D2750). 
 
You asked the Plan to pre-approve a crown. You say that you are suffering with the appeal taking so long. The 
Plan denied your request. The Plan says that that the crown (D2750) is not medical necessary. 
 
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. The Plan did not provide the medical records they used in their review. The Plan 
has not supported their decision to deny your request. Therefore, we decided that the Plan has to pre-approve a 
porcelain crown on tooth #21 (D2750).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on February 25, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the resin-based composite. You say that a Plan representative never indicated 
that the Plan does not accept out-of-network providers. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advance. 
  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 resin-
based composite only when provided in-network and 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 the resin-based composite have not been met because they were provided out-of-network. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) provided on 
February 25, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for periodontal scaling and root planing. We also decided that the Plan 
does not have to pay for debridement of a peri-implant defect.  You asked the Plan to pay for periodontal scaling and root planing and debridement of a peri-implant defect. 
You say that services were necessary as an infection needed to be addressed to save the implant and adjacent 
teeth. The Plan says that periodontal scaling and root planing and debridement of a peri-implant defect are not 
listed as covered benefits under your dental Plan. 
 
We decided that the Plan has to pay for periodontal scaling and root planing.  
 
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 periodontal 
scaling and root planing every two years. The Plan did not give any indication or proof that this benefit has 
been exhausted. Therefore, we decided that the Plan has to pay for the periodontal scaling and root planing 
provided on February 16, 2022. 
 
We also decided that the Plan does not have to pay for debridement of a peri-implant defect.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the debridement of a peri-implant 
defect is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the debridement of a peri-implant defect provided on February 16, 2022. 
 
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.