Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toggle switch (K0108), a positioning belt/safety 
belt/pelvic strap (E0978), a harness for an upgrade to an expandable controller (E2313) and an expandable 
controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are all medically 
necessary. The Plan denied your request. The Plan says the toggle switch cannot be approved as it is already 
included with the requested expandable controller. The electrical connection between the wheelchair controller 
and two or more motors, expandable controller and harness cannot be covered, there is not a medical need to 
control these power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the seat belt is already provided 
with the approved wheelchair. The toggle switch is already a part of the expandable controller requested. 
Provided records document that the enrollee has 4-/5 to 4+/5 bilateral upper extremity strength thus indicating 
she has adequate upper extremity strength to operate the wheelchair's power options with their 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a toggle switch (K0108), a positioning belt/safety belt/pelvic strap (E0978), a 
harness for an upgrade to an expandable controller (E2313) and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on  
April 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you cannot afford these 
charges. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $30 
copayment for provider and professional services received in a specialist's office setting.  
 
 
  You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits, 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 copayment for a specialist office visit provided on April 18, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222, D9223) for tooth # 
01, two or more administrations of therapeutic parenteral drugs (D9612) for tooth #01, and alveoloplasty not in 
conjunction with extractions (D7321) for tooth #12 provided on March 15, 2022. 
 
You asked the Plan to pay for deep sedation/general anesthesia (D9222, D9223) for tooth # 01, two or more 
administrations of therapeutic parenteral drugs (D9612) for tooth #01, and alveoloplasty not in conjunction 
with extractions (D7321) for tooth #12. You say that this surgery was medically necessary. You also say that at 
75 years of age, being diabetic with other medical problems, the denied anesthesia was instrumental in your 
care. The Plan denied your request. The Plan says these services are not covered under your 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 deep 
sedation/general anesthesia (D9222, D9223) for tooth # 01, two or more administrations of therapeutic 
parenteral drugs (D9612) for tooth #01, and alveoloplasty not in conjunction with extractions (D7321) for tooth 
#12 provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220), resin-based 
composite (D2332), and simple extraction (D7140) provided on March 30, 2022, and May 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you paid for these procedures in full. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-
sharing amount when your services are received from an out-of-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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 the first intraoral periapical x-ray (D0220), 
resin-based composite (D2332), and simple extraction (D7140) provided on March 30, 2022, and May 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on March 3, 2022.
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with Medicare rules, as the required DEX Z-Code is missing from this claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code identifier. We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management analysis of 11 endogenous analytes 
provided on March 23, 2022. 
 
You asked the Plan to pay for the pain management analysis of 11 endogenous analytes. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The pain management analysis of 11 endogenous analytes test at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the pain management analysis of 11 endogenous analytes provided on March 
23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), gingival 
irrigation (D4921), and an office visit after regular hours (D9440) provided on May 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary as it was 
an emergency. The Plan denied your request. The Plan says the services at issue are not covered 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 an 
intraoral periapical radiographic image (D0220), gingival irrigation (D4921), and an office visit after regular 
hours (D9440) provided on May 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on May 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware 
the treating provider was OON, and they did not tell you they were OON. The Plan denied your request. The 
Plan says the dental services were received from an OON provider and are not covered by your supplemental 
benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
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 record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested services are not covered under this benefit when 
received from an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120) and prophylaxis (D1110) provided on May 18, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a transit option 
(K0108), an expandable controller upgrade (E2377), an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311) and a harness for upgrade to expandable controller 
(E2313). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says a seat elevator and electronic 
connection for a power seat elevation do not serve a primary medical purpose and is statutorily non-covered. 
Although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. The requested accessories are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a transit option 
(K0108), an expandable controller upgrade (E2377), an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311) and a harness for upgrade to expandable controller 
(E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the power seat elevation is a non-covered 
accessory because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (81404) provided on May 14, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no evidence to 
support the ordering provider was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show that the testing in question was ordered by 
the enrollee's treating physician as required by Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing (81404) provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 1, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test identifies underlying causes of pain. 
The Plan denied your request. The Plan says the testing is considered screening in nature and not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The test at issue assesses the likelihood of contributing factors of pain and 
recommends medications. Medications should be provided based on the presence of a diagnosis and should be 
adjusted based on a patient's response to the medication. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are at home and at risk for falls, breaks and re-
hospitalization. The Plan denied your request. The Plan says admission to IRF was denied as not meeting 
criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing facility level 
of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the record indicates that you have diabetes with high blood sugars, end stage 
renal disease on peritoneal dialysis and weakness. You also require physical therapy but not of high intensity. 
The record does not indicate that you have complex medical needs requiring an acute inpatient stay services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical extraction (D7210) provided on May 12, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that 
prior to receiving any dental work, you contacted the Plan and were told that all dental was covered up to 
$1,000. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. The Plan also says that you contacted the Plan 
prior to the date of service to verify benefits and provider eligibility, and you were provided with a copy of 
your plan benefits and several in-network providers. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested services are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) and surgical extraction (D7210) provided on May 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued observation services provided
beyond March 22, 2021.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal, continued
observation stay services were medically necessary. The Plan denied your request. The Plan says you were
given notice that continued observation services would not be covered, and that care would need to be provided
at a lower level of care. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
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. Your request for continued care in the observation
unit was due to social issues with difficulty involving your family's ability to care for you at home. Based on
the medical records provided, your care needs were custodial in nature which once the observation services
ceased which is not covered by Medicare. 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 provide
coverage for continued observation services provided beyond March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LentiGlobin BB305 gene therapy. 
 
You asked the Plan to pre-approve LentiGlobin BB305 gene therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for 
coverage have not been met because the requested services are experimental/investigational. 
 
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 LentiGlobin BB305 gene therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that to date the use of LentiGlobin BB305 gene therapy is investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LentiGlobin BB305 gene therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve LentiGlobin BB305 gene therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you did not receive the materials to review 
providers that were available under your plan. The Plan denied your request. The Plan says the dental service 
was received from an OON provider and is not covered by your 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. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested or service is not covered under this benefit when 
received from an OON provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis 
(D1110) provided on February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
October 1, 2021. 
 
You asked the Plan to pay for the hospital discharge day management. You say that you would like payment to 
be reconsidered for the services performed. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on this date of service, and traditional Medicare is the primary payer when in hospice care. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
October 1, 2021.