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

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by a 
participating provider on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not been to a dentist in the past year. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 1, 2020. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
by a participating provider on August 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) 
provided on August 26, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you disagree with the copayment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient diagnostic tests/Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for MRI. However, you are being asked to pay $240.65 which 
is less than the required amount. 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 Magnetic resonance 
imaging (MRI) provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dental services provided on October 22, 
2021. 
 
You asked the Plan to waive the copayment for dental services. You say that the services provided should be 
covered, the enrollee should not be responsible. The Plan denied your request. The Plan says the provider has 
opted out of the Medicare-program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
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. Therefore, we decided that the Plan does not have to waive the 
copayment for dental services provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on September 6, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that this was a simple cleaning. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided by an out-of-network provider on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic tooth #'s 7, 8, and 9 (D2740), and core 
buildup, including any pins when required tooth #'s 7, 8, and 9 (D2950). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #'s 7, 8, and 9 (D2740), and core 
buildup, including any pins when required tooth #'s 7, 8, and 9 (D2950). You say that the enrollee wants a new 
crown bridge as it is very old and causes food impaction and sensitivity due to open margin, secondary decay, 
and causes discomfort. The Plan denied your request. The Plan says that the rules for the requested services 
have not been met. 
 
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 crown - 
porcelain/ceramic tooth #'s 7, 8, and 9 (D2740), and core buildup, including any pins when required tooth #'s 7, 
8, and 9 (D2950). 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 crown - porcelain/ceramic tooth #'s 
7, 8, and 9 (D2740), and core buildup, including any pins when required tooth #'s 7, 8, and 9 (D2950). Our 
reviewer says that the services are medically necessary. Our physician reviewer found that the documentation 
indicates that the crowns in place are defective (open margins and recurrent caries) causing food impaction and 
patient sensitivity. It is medically reasonable and necessary to replace these crowns to provide adequate 
function and patient comfort. 
 
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 crown - porcelain/ceramic tooth #'s 7, 8, and 9 (D2740), and core buildup, 
including any pins when required tooth #'s 7, 8, and 9 (D2950). have been met. Therefore, we decided that the 
Plan has to pre-approve a crown - porcelain/ceramic tooth #'s 7, 8, and 9 (D2740), and core buildup, including 
any pins when required tooth #'s 7, 8, and 9 (D2950).  

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says its safety and efficacy has not been established. 
 
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 requested services. Our physician 
reviewer found that the enrollee has left ventricular dysfunction and continued symptoms, despite medical 
treatment, thought to reflect congestive heart failure. An implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM) was requested. While clinical studies led to a Food 
and Drug Administration (FDA) approval, CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, the requested CCM system is not considered medically necessary in this enrollee. 
 
 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Optimizer Smart implantable pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental service. You say that the evaluation was necessary and should be 
covered. The Plan denied your request. The Plan says the service received is not covered by Medicare; 
therefore, the service is denied. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested wheelchair is medically 
necessary. The Plan denied your request. The Plan says the request wheelchair is not medically necessary 
because records show the enrollee does not have mobility limitations preventing participation in MRADLs, or 
mobility limitations are not resolved with use of an assistive device. The enrollee was evaluated by an 
occupational therapist who reported he is able to ambulate with a cane, transfer on and off a scooter, break 
down the scooter, and store it in his car. 
 
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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve a computerized tomography (CT) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says a repeat CT 
scan of the brain is not reasonable or medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 pre-approve a computerized tomography (CT) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found Based upon the 
history and the findings on the November 11, 2022, magnetic resonance imaging (MRI) a repeat MRI is 
reasonable and should be approved if requested.  A repeat CT scan would be of no value in this case, and it 
appears the intention was to order MRI rather than a CT scan. 
 
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 computerized tomography (CT) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized tomography (CT) scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Infliximab for the enrollee.
You asked the Plan to provide coverage for Infliximab. You say that Infliximab 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 Medial Director looked at the case file and the reopen request. At issue is coverage for Infliximab.
The Maximus Physician Reviewer determined that the requested Infliximab was medically reasonable and
necessary in this case.
The Plan requested a reopen and argues the diagnosis of immune-related mucositis esophagitis is not
considered a medically accepted indication for Infliximab. The medical records show the enrollee is a 73-year old
man with metastatic squamous cell carcinoma of the left tonsil. The enrollee was treated with
Pembrolizumab, but this was discontinued because of the development of severe immune mucositis and
esophagitis. The mucositis and esophagitis were refractory to treatment with IV and oral steroids.
The Plan is correct in this case. There is insufficient evidence to support the use of Infliximab in the treatment
of steroid-refractory immune mucositis and esophagitis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Infliximab have not been met. Therefore, we decided that the Plan does not
have to provide coverage for Infliximab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2750), an implant (D6110), and the 
precision attachments (D6950) for tooth #22 and #27 provided on June 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the dental procedures were medically 
necessary. The Plan denied your request. The Plan says your annual dental benefit has already been exhausted. 
The denial of payment for the implant and precision attachments is correct, because they are not covered by the 
Plan. 
 
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, certain limitations apply. The record 
shows your annual dental benefit was exhausted on date of service June 14, 2022. Prior to the date of service, 
the Plan paid a total of $100.05 towards dental services. On June 14, 2022, the Plan paid $899.95 towards the 
dental services that were provided; therefore, the annual dental benefit of $1,000 ($100.05 paid + $899.95 paid) 
was met. The implant and precision attachments are not covered under the dental benefit. Therefore, we 
decided that the Plan does not have to pay more for the crowns (D2750), an implant (D6110), and the precision 
attachments (D6950) for tooth #22 and #27 provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789, and drug testing 
billed with code 80307 for date(s) of service March 31, 2022. 
 
You asked the Plan to pay for codes 83789 and 80307. You say that this service is medically necessary and 
should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable. The Plan also says that code 80307 is not covered because it was not authorized and was provided by a non-network 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also say that 
Plans can restrict members to using network providers and may require prior authorization for services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 83789 and 80307 have not been met. Specifically, we find that the testing described by code 
83789 is not separately payable. In addition, for code 80307, your lab is not a network provider with the Plan 
and you did not have authorization to perform code 80307.  The referring provider for this service is also not a 
network provider with the Plan. Therefore, we decided that the Plan does not have to pay for validity testing 
billed with code 83789, and drug testing billed with code 80307 for date(s) of service March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your
request. The Plan says that the enrollee does not meet the Medicare criteria for admission to an IRF. 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 IRV care. Our
Medical Director states the documentation does not support that the complexity of this enrollee's nursing,
medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care, and that the enrollee required at least 3 hours a day, 5 days a week, or 15 hours over 7
consecutive days, of therapy services. Our Medical Director found that the enrollee's condition did not meet
Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal with an insertion of an 
intraocular lens. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is not on prescription medication for glaucoma. 
 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 requested services. Our physician 
reviewer found that the enrollee complains of blurry vision while driving and wants to undergo cataract 
surgery. Ocular medications are listed as dry eye over the counter eye drops as needed. In this case, the 
available documentation does not indicate that the enrollee is currently being treated with an ocular 
hypotensive medication. Therefore, criteria are not met for medical necessity of the requested service.  
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve extracapsular cataract removal with an insertion of an intraocular lens.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0220 and D0230) provided by an out-of-network provider on June 13, 2022, and June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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. 
 
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 items or 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 a limited oral evaluation (D0140) and intraoral imaging (D0220 and D0230) provided by an out-of-
network provider on June 13, 2022, and June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 24, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for a 
covered indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 24, 2022.