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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth per 
quadrant (D4342) provided on April 8, 2022 to April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and would like the 
plan to reconsider. 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 periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided on April 8, 
2022 to April 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74177 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 74177. The Plan denied your request. The Plan says payment for 
code 74177 is bundled into payment for code 74174. 
 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 74177 
is a column II code to column I code 74174. 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 74177 billed for date of service May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail. 
 
You asked the Plan to pre-approve these services. You say that you have fallen in the bath many times and 
have back pain. The Plan denied your request. The Plan says the services 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 bathtub wall rail.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #11 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says that that the tooth does not appear to have significant breakdown due 
to decay or trauma. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown 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 a crown. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that a review of the documentation indicates that 
tooth #11 has a large defective restoration with recurrent caries. A crown restoration is medically reasonable 
and necessary to provide the support and strength for adequate masticatory function and use as an abutment for 
a removable partial denture. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #11 (D2740).  
 
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 acupuncture treatment provided on December 17, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided on 
December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller 
harness (E2313) electronic connection between wheelchair controller and one power seating system motor 
(E2310) and a privacy flap (K0108). 
 
You asked the Plan to pre-approve upgraded electronics and privacy flap. You say that please review the 
attached medical documentation to support the need of the custom medical equipment being requested. The 
Plan denied your request. The Plan says the privacy flap does not serve a medical purpose and There is not a 
medical need to control power options through the joystick. 
 
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 upgraded electronics and privacy flap. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, criteria for a power wheelchair are met. The requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics and privacy flap have not been met. Therefore, we decided 
that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness 
(E2313) electronic connection between wheelchair controller and one power seating system motor (E2310) and 
a privacy flap (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custodial care. 
 
You asked the Plan to pre-approve the custodial care. You say that the custodial care is necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, 
we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the 
Plan does not have to pre-approve the custodial care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99497 billed for date of service June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments on tooth #3, 4, 5, 12, 14, 18, 19, 30, 
and 31 (D6057), abutment supported crowns on tooth #3, 4, 5, 12, 14, 18, 19, 30, and 31 (D6058), and 
endosteal implants on tooth #3, 4, 5, 12, 14, 18, 19, 30, and 31 (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted during the authorization of this claim. 
Therefore, we decided that the Plan does not have to pre-approve custom abutments on tooth #3, 4, 5, 12, 14, 
18, 19, 30, and 31 (D6057), abutment supported crowns on tooth #3, 4, 5, 12, 14, 18, 19, 30, and 31 (D6058), 
and endosteal implants on tooth #3, 4, 5, 12, 14, 18, 19, 30, and 31 (D6010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Signafuse ceramic-based allograft during approved 
surgery. 
 
You asked the Plan to pre-approve Signafuse ceramic-based allograft during approved surgery. You say that 
the requested Signafuse ceramic-based allograft during approved lumbar decompression and fusion surgery is 
medically necessary. The Plan denied your request. The Plan says the requested Signafuse ceramic-based 
allograft during approved lumbar decompression and fusion surgery is 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 Signafuse ceramic-based allograft 
during approved surgery. Our reviewer says that the requested Signafuse ceramic-based allograft during 
approved lumbar decompression and fusion surgery is not medically necessary. Our physician reviewer found Signafuse ceramic allograft is experimental. More research is needed to show safety and efficacy of this 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Signafuse ceramic-based allograft during approved surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Signafuse ceramic-based allograft during 
approved surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
May 17, 2022, and May 19, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. 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 $60 
copayment for each Medicare covered radiation therapy service for a computerized tomography (CT) scan. 
However, the allowed amount for each date of service is $48.91, therefor the total amount owed is $97.82. 
 
You have been asked to pay a $60 copayment for each Medicare covered radiation therapy service for a 
computerized tomography (CT) scan. This item/service falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
computerized tomography (CT) scan on May 17, 2022, and May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse Bone Morphogenic Protein (BMP) allograft for 
use during approved surgery. 
 
You asked the Plan to pre-approve Infuse Bone Morphogenic Protein (BMP) allograft. You say that the 
requested Infuse Bone Morphogenic Protein (BMP) allograft is medically necessary. The Plan denied your 
request. The Plan says the requested Infuse Bone Morphogenic Protein (BMP) allograft is 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 Infuse Bone Morphogenic Protein 
(BMP) allograft. Our reviewer says that the requested Infuse Bone Morphogenic Protein (BMP) allograft is not 
medically necessary. Our physician reviewer found iliac crest autograft is the gold standard graft material. The Food and Drug Administration (FDA) has not approved BMP for use from a posterior approach in the lumbar 
or thoracic spine. It is not medically needed in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infuse Bone Morphogenic Protein (BMP) allograft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Infuse Bone Morphogenic Protein (BMP) 
allograft for use during approved surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a panniculectomy is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have an 
umbilical hernia and excessive skin folds with redness and a caesarean section scar. The records do not 
document the presence of complicating factors, such as inability to walk normally, chronic pain, ulcers created 
by the abdominal skin fold, or rash (intertrigal dermatitis). There is no documentation that these symptoms 
have been present for at least three months and haven't been helped by standard medical therapy. The criteria for coverage are not met and the panniculectomy is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a panniculectomy.  
 
Local Coverage Determination (LCD) L39051 referenced by the Plan is for the incorrect jurisdiction and was 
not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim complete mandibular denture (D5811), a 
complete mandibular denture (D5120), and three extractions (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an interim complete mandibular denture (D5811) and a 
complete mandibular denture (D5120) are not covered by your dental benefits. The Plan also says that your 
benefit for an extraction 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, dentures are not among those covered 
under this benefit. The record shows the Plan approved one extraction, therefore, your benefit for extractions 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an interim complete 
mandibular denture (D5811), a complete mandibular denture (D5120), and three extractions (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for services provided on 
January 19, 2021. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code was not 
billed as required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99153 is a technical component only code. This code is not payable as a professional 
component. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
services provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a canal preparation procedure to fit and place a post in 
tooth #7 (D3950). 
 
You asked the Plan to pre-approve the dental services. You say that the procedure is related to a crown that 
needs to be placed. You say the services should be covered because your provider placed an authorization for 
the procedure. The Plan denied your request. The Plan says the claim was processed correctly. Your dental 
coverage does not extend to the requested services. 
 
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 a 
canal preparation procedure to fit and place a post in tooth #7 (D3950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on May 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80307) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services received were medically necessary. 
The Plan denied your request. The Plan says the 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 the dental 
services on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for whitening trays (D0001), and unspecified removable 
prosthodontic procedure (D5899) provided on April 26, 2022. 
 
You asked the Plan to pay for whitening trays (D0001), and unspecified removable prosthodontic procedure 
(D5899). The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 whitening 
trays (D0001), and unspecified removable prosthodontic procedure (D5899) provided on April 26, 2022.