Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the efficacy (effectiveness) of this procedure cannot be established by review of the 
available published peer review (medical) 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested bioimpedance spectroscopy is not medically necessary as its effectiveness for the 
treatment of lymphedema has not been documented in the peer-reviewed literature. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deep gum and root cleaning for the lower quadrant. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the tooth must have noticeable bone loss, or show on an x-ray that there is a 
hard substance buildup. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested Our physician reviewer found the documentation provided does not meet the criteria for 
coverage for scaling and root planing (D4341) for the lower right and left quadrants. Diagnostic radiographs 
are required to determine the presence of subgingival calculus and areas of bone loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a deep gum and root cleaning for the lower quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on December 
14, 2021. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you went with the least costly option 
that will provide future savings going forward, and believe this should be covered. The Plan denied your 
request. The Plan says this procedure is not a benefit under the dental 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, the requested items or services are not 
among those covered under this benefit. The only type of denture related services that are covered under your 
plan are denture reline and repairs. Therefore, we decided that the Plan does not have to pay for the maxillary 
partial denture (D5213) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310, 
D7311). 
 
You asked the Plan to pre-approve alveoloplasty services. You say that these services are necessary. The Plan 
denied your request. The Plan says they have agreed to cover the surgical extractions, identified with code 
D7210; however, the alveoloplasty procedures are not covered by the Plan and were not submitted with enough 
information (including the location where they are to be performed) for review. 
 
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 
alveoloplasty in conjunction with extractions (D7310, D7311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and 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 the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genicular nerve blocks and genicular nerve ablation are considered investigational and not medically 
necessary for the treatment of chronic knee pain, including, but not limited to any of the following -  
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment 
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 
surgery. 
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the first intraoral periapical x-ray (D0220). We decided that the Plan 
does not have to pay more for the periodic oral evaluation (D0120), panoramic x-ray (D0330), and prophylaxis 
(D1110).  
 
You asked the Plan to pay for the first intraoral periapical x-ray (D0220) and to pay more for the periodic oral 
evaluation (D0120), panoramic x-ray (D0330), and prophylaxis (D1110) provided on February 11, 2022 by an 
out-of-network (OON) provider. You say that your dentist advised this x-ray was necessary to confirm if the 
tooth was infected because he suspected an abscessed tooth. The Plan says that this claim processed correctly. 
 
We decided that the Plan has to pay for the first intraoral periapical x-ray (D0220).  
 
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 specifics on why the first intraoral periapical x-ray 
(D0220). The submitted documentation only states that the intraoral x-ray was denied because the payment 
provided for major procedure service is inclusive to the major procedure. The records do not show what the 
major procedure service was, nor is there proof of how the intraoral x-ray was considered as part of the major 
procedure. First intraoral periapical x-ray (D0220) is listed in the 2022 Evidence of Coverage as a covered 
service without any limitations. Consequently, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to pay for the first intraoral periapical x-ray (D0220), and you 
will be responsible for the $10 copayment plus the difference between the billed amount and allowed amount.  
 
We also decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), 
panoramic x-ray (D0330), and prophylaxis (D1110). 
 
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, you are responsible for a $10 
copayment per service, plus the difference between the billed amount and allowed amount because these 
services were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic 
oral evaluation (D0120), panoramic x-ray (D0330), and prophylaxis (D1110). 
 
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 pay for the request for medical records provided on August 18, 2021. 
 
You asked the Plan to pay for the request for medical records. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a service that is covered by Medicare or by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. In this case, the request for medical records is not a service that is 
covered by the Plan. Based on this information, we decided that Medicare rules for coverage of the request for 
medical records have not been met. Therefore, we decided that the Plan does not have to pay for the request for 
medical records provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay the maximum allowable eyewear benefit of $200 for eyewear provided on 
January 27, 2022. 
 
You asked the Plan to pay the maximum allowable eyewear benefit of $200 for the eyewear. The Plan denied 
your request. The Plan says that the claim processed correctly. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the claim has not been paid according to the 
Plans maximum allowable eyewear benefit of $200. Therefore, we decided that the Plan has to pay the 
maximum allowable eyewear benefit of $200 for eyewear provided on January 27, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for full replacement of a Group 3 Power
wheelchair and accessories for the enrollee.
You asked the Plan to provide coverage for full replacement of a Group 3 Power wheelchair and accessories.
You say that the enrollee's current equipment is more than five years old and full replacement is medically
necessary. The Plan denied your request. The Plan says the records provided do not show full replacement is
necessary and the current equipment is less than five years old. Maximus overturned the Plans denial for
medical necessity. However, upon additional review it was found the issue was not medical necessity but the
fact that the equipment was not eligible for full replacement.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for replacement of durable medical equipment. The records show the current equipment was approved in
March of 2019, which is less than five years old. The equipment evaluation does not indicate the current
equipment cannot be repaired.
The Attendant Control (E2331) cannot be covered for a wheelchair with a user-operated control. The enrollee
does not have any condition for which power elevating leg rests are medically needed and push handles do not
serve a primary medical purpose. Finally, the E2311 Electronic connection (E2311), Expandable Controller
(E2377) and Expandable Controller Harness (E2313) cannot be covered as it is not medically necessary to
control the three requested power options through the joystick (drive interface). Therefore, we decided that the
Plan does not have to provide coverage for full replacement of a Group 3 Power wheelchair and accessories for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage 
criteria for epidural steroid injections. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there is no imaging of the thoracic spine which corresponds to symptoms. This does not meet the LCD criteria 
and therefore is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON office visit. You say that you are supposed to be having 
chemotherapy and some of the medications are harsh on your body. You also say that you would like to be seen 
by another type of specialist to minimize the side effects of the chemotherapy. The Plan denied your request. 
The Plan says the requested services can be provided by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 13, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 93040-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93040 is "Rhythm ECG, 1-3 leads; with interpretation 
and report." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report does not support 
modifier -59. CPT 93040 would be inclusive to CPT 95921, as CPT 95921 is the more comprehensive 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for imaging services provided to the enrollee on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve a second opinion to be provided by the requested out-of-network provider. 
You say that the enrollee has a unique clinical situation and prior history of definitive prostate cancer therapy 
to full dose, and now with extensive anal cancer that overlaps the same area. You say this is not a situation that 
can be treated with conventional radiation therapy to a curative dose without an extremely high risk of 
complications such as fistula & necrosis. The Plan denied your request. The Plan says the services are available 
in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve a second opinion to be provided by the requested out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-level referral to an otolaryngologist (ENT). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the tertiary level of care 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 the referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the limited documentation in the case file does not support that the enrollee in this case requires ENT 
care that is only available at a tertiary level. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary-level referral to an otolaryngologist (ENT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on January 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing provided on January 24, 2022 by 
an out-of-network (OON) provider.
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 January 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that according to the 
summary pages of your 2022 benefits book, you should only be responsible for a $40 copay because everything 
else says $0 coinsurance. The Plan denied your request. The Plan says these services were performed by a non-
participating provider, and you are responsible for any difference between the Maximum Allowable Fee and 
the amount the provider bills you for the services. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference 
between the billed amounts and allowed amounts because these services were received OON. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 4, 2022 by an out-of-network (OON) provider.