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

 
We decided that the Plan does not have to pay for crown porcelain/ceramic (D2740) and core buildup including 
pins (D2950) provided on November 29, 2022. 
 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your annual $3000 maximum was met; any remaining charges are your responsibility. 
 
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 met. Therefore, we decided that the Plan does not have to pay for crown porcelain/ceramic (D2740) and core buildup including pins (D2950) provided on 
November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 4, 2022, to January 18, 2022.
You asked the Plan to pay for the home health services as billed. You say that the plan has not given guidance on how to submit the Notice of Admission. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. The first date of home health services for the 2022 year was January 4, 2022. The NOA filed with the Plan has a date of January 1, 2022, when it should be January 4, 2022. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 4, 2022, to January 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for in-home podiatry services provided on December 28, 2022. 
 
You asked the Plan to pay for in-home podiatry services. You say that you assumed that prior authorization 
was obtained prior to the services being rendered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for in-home podiatry 
services provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis - adult (D1110) provided on October 6, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the out-of-network cost 
share amount of $55 for dental code D1110 received on October 6, 2022. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for prophylaxis - adult (D1110) provided on 
October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point injections provided on October 11, 2022. 
 
You asked the Plan to pay for the trigger point injections. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the trigger point 
injections provided on October 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 26, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visit. You say that you want to see this out-of-network 
provider. The Plan denied your request. The Plan says there are providers within your Plan's network that are 
available and can provide this service. 
 
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 
the specialist visit to be provided 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 Dexcom G6 continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the Dexcom G6 continuous glucose monitor (CGM) and supplies. The Plan 
denied your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 continuous glucose monitor (CGM) and supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
Sensor.  
You asked the Plan to pre-approve the Dexcom G6 CGM Sensor. You say that the sensor is a medical 
necessity. You also say that the enrollees mother used a FreeStyle Libre system and had many issues with it. The enrollee stated that it was not accurate or user friendly so this has deterred him from wanting to use  a 
Libre system. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC 
are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G6 CGM. The member has not had a trial of the preferred Freestyle CGM and there was no 
explanation as to why a preferred CGM could not be used other than as a personal preference. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x 12) and implant 
supported crowns (D6065 x 25). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the 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 
prefabricated abutments (D6056 x 12) and implant supported crowns (D6065 x 25).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 1, 2022, to March 30, 2022.
You asked the Plan to pay for the home health services as billed. You say that a Notice of Admission was submitted on March 2, 2022. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. The admission date is November 1, 2021, and not the NOA date of January 30, 2022. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 1, 2022, to March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cone beams (D3081 and D0382). 
 
You asked the Plan to pre-approve the dental services. You say that you are getting a root canal and the dentist 
needs to do the cone beams to decide to fix it. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because cone beams 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 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 
cone beams (D3081 and D0382).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns resin-based indirect (D2710) for teeth numbers
8 and 9.
You asked the Plan to pre-approve the crowns. You say that you do not have the money to pay your part. 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 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 benefit for the requested item or service was exhausted on date of service December 23, 2022.
Therefore, we decided that the Plan does not have to pre-approve crowns resin-based indirect (D2710) for teeth
numbers 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator provided on November 24, 2022. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a neuromuscular 
stimulator provided on November 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PalinGen skin substitute for the enrollee.
You asked the Plan to pre-approve the PalinGen skin substitute. You say that this is medically necessary. The Plan denied your request. The Plan says that the medical studies do not show proof that this procedure is helpful.
Our Medical director looked at the case file and the reopen request. At issue is coverage for PalinGen skin substitute. Our Medical Director states that the clinical documentation does not support that the PalinGen skin substitute was medically reasonable and necessary for the enrollee in this case. The case file does not document when the wound occurred. The size of the wound is not documented. The clinical documentation does not support the reference regarding the removal of sutures. In addition, it is noted on 10/24/2022 that the wound was "improved with treatment." The case file does not contain documentation of failure to respond to conservative wound care measures over a period of four weeks. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the PalinGen skin substitute.
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 PalinGen skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve the PalinGen skin substitute for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for body powered fingers (code L6715 ).
You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this
equipment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for body powered
fingers under code L6715 described as a terminal device, multiple articulating digits, includes motor(s), initial
issue or replacement. The Plan requested a reopen and notes code L6000, which is a complete terminal device,
had already been approved. The Plan notes code L6715 cannot be used with the already approved L6000. Code
L6715 is a terminal device. Code L6000 is a complete terminal device. Code L6715 x 2 are duplicate services
that cannot be approved, as explicitly stated in the Medicare coding guidelines for Upper Limb Prostheses -
Correct Coding. The medical records show the enrollee was a then 71-year-old man who underwent a left-hand
4th and 5th ray amputation, which involves the removal of the entire finger along with the corresponding
metacarpal bones in the hand. The orthopedic surgeon states the enrollee needs body powered point design
fingers to use and assist in everyday tasks. The Plan approved L6000, partial hand, thumb remaining. The Plan
is correct in this case. The clinical documentation does not support that code L6715 was medically reasonable
and necessary for the enrollee in this case based on the Plans approval of L6000.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for body powered fingers (code L6715).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on July 14, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pap smear and office visit provided on October 14, 2022. 
 
You asked the Plan to pay for a pap smear and office visit. You say that you have been this patients pcp for 
years and should not need prior authorization or a referral for this. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pap smear and office 
visit provided on October 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64491, 64490) for the enrollee.
You asked the Plan to pre-approve facet joint injections. You say that this service is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
Our Medical director looked at the case file and the reopen request. At issue is coverage for facet joint injections. Our Medical Director states that clinical documentation is limited and does not support that the coverage criteria, as established by the LCD, were met.
It is not sufficiently documented that the enrollee had functional deficit measured on pain or disability scale and had failure to respond to noninvasive conservative management (as tolerated), and that there was no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of facet joint injections. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64491, 64490) for the enrollee.