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

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 20, 2022.
You asked the Plan to pay for this testing. You say that this test kit should be paid for by the Plan. The Plan
denied your request. The Plan says this test is covered by Original Medicare. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The
Plan states that contract addendum coverage sent to all enrollees indicated coverage for home tests would be
provided beginning on February 1, 2022. This purchase does not qualify for that benefit.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Plans were given the option
to cover home testing kits as a supplemental benefit but were not required to do so by Medicare.
The Plan communicated to enrollees that this testing would be covered supplementally free of charge after
February 1, 2022. Therefore, we decided that the Plan does not have to pay for a home COVID-19 test
purchased on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
February 24, 2021, and an adjunctive pre-diagnostic test (D0431) provided on August 26, 2021. You asked 
the Plan to pay for an adjunctive test and fluoride varnish. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says your benefit for the topical application of 
fluoride varnish has already been exhausted. The Plan also says that an adjunctive pre-diagnostic test (D0431) 
is not covered by your dental benefits. 
 
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 topical application of fluoride varnish was exhausted on date of service August 26, 
2021. An adjunctive pre-diagnostic test (D0431) is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
February 24, 2021, and an adjunctive pre-diagnostic test (D0431) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) of tooth # 18 provided on 
March 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why this service is not 
covered since you have a supplemental plan. You say that your supplemental plan covers simple extraction. 
You also say that you feel that at least some of this should be paid. The Plan denied your request. The Plan says 
the surgical extraction is not listed as covered service. 
 
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 surgical extraction is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical 
extraction (D7210) of tooth # 18 provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #3 (D7210) provided on February 22, 2022. 
 
You asked the Plan to pay for an extraction. You say that you feel this service should be covered. The Plan 
denied your request. The Plan says an extraction (D7210) is not covered by your dental benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for an 
extraction of tooth #3 (D7210) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
gene are a statutorily excluded service. 
 
We looked at the file and Medicare rules. The panel performed included the FANCC gene and is non-covered. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the gym membership purchased on January 1, 2021. 
 
You asked the Plan to pay more for the gym membership. You say that you were only partially reimbursed 
$150 of the requested $450 for the gym membership benefit for 2021. The Plan denied your request. The Plan 
says in total, you have reached your 2021 maximum reimbursement of $250. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $250 
per calendar year for gym benefits. 
 
The Plans rules for coverage of gym benefits have not been met because your Wellness Allowance benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay more for the gym membership 
purchased on January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no pre-post measurements over four weeks to support a good faith trial with 
the basic pump before the request for an advanced pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have lymphedema of the chest, trunk, or abdomen on the treating provider 
medical progress notes. The patient does not have unique characteristics that would indicate the segmented 
pump over a standard pump on the submitted documentation. The documentation does not reveal a four week 
trial of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal (L5981) and all lower extremity prostheses, multi-axial rotation unit (L5986) 
 
You asked the Plan to pre-approve the advanced foot and ankle features. You say that the physician notes 
specifically state that the enrollee has realistic potential to ambulate with a K3 featured foot and has classified 
them as meeting K3 requirements. The Plan denied your request. The Plan says the requested components 
exceeds the enrollee's needs. There are alternative foot ankle units that may meet the enrollee's needs. 
 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 advanced foot and ankle features. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support that the enrollee is a K3 ambulator. 
The documentation discusses that the enrollee would benefit from a power assist manual wheelchair and that 
the enrollee has cardiovascular and orthopedic issues causing functional limitations impairing age appropriate 
activities of daily living. These activities include, but are not limited to, walking, bathing, dressing, personal 
hygiene, and normal household chores, as well as fitness and sporting activities. Furthermore, the requested 
foot is the Ossur Pro-Flex XC. Per an online review of this foot it was developed to comfortably accommodate 
relatively active users, who enjoys hiking and jogging, as well as level-ground walking. The foot has deluxe 
features that are not medically necessary such as an aesthetically pleasing, anatomical foot cover. The foot is 
waterproof and fully resistant to both chlorine and salt water submersion. The documentation does not reveal 
the patient will participate in water submersion activities, be jogging or hiking. The documentation does not 
support the need for the requested items. 
 
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 advanced foot and ankle features have not been met. Therefore, we decided 
that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) 
and all lower extremity prostheses, multi-axial rotation unit (L5986)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced foot/knee and ankle rotational units 
represented by codes L5828, L5848, L5848, L5856, L5980, L5984 and L5986. 
 
You asked the Plan to pre-approve codes L5828, L5848, L5848, L5856, L5980, L5984 and L5986. You say 
that the items which remain in dispute are medically necessary. The Plan denied your request. The Plan says a 
prosthetic leg with a foot/knee that is used for a lower activity level may meet the enrollee's needs. The Plan 
says that the rotational units are not needed since the advanced foot is denied. 
 
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 codes L5828, L5848, L5848, L5856, 
L5980, L5984 and L5986. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the prosthetic evaluation indicates this is for an Otto Bock Maverick Comfort AT Foot. The documentation is not consistent that the enrollee's activities require a K3 level 
microprocessor. The requested foot also has features that exceed the enrollee's medical and functional needs. 
The documentation does not reveal that the enrollee's activities require water submersion. The requested items 
are waterproof with allowable environmental conditions including fresh water, salt water, and chlorine water. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5828, L5848, L5848, L5856, L5980, L5984 and L5986 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve advanced foot/knee and ankle rotational 
units represented by codes L5828, L5848, L5848, L5856, L5980, L5984 and L5986.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 
15, 2021, to October 26, 2021. 
 
You asked the Plan to pay for the SNF care provided from October 15, 2021, to October 26, 2021. You say that 
the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
was no longer receiving daily skilled services during the dates of service in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care provided from October 15, 
2021, to October 26, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. 
Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care provided from have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 15, 2021, to 
October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial thyroid lobectomy (60210) provided on March 2, 
2022. 
 
You asked the Plan to pay for the partial thyroid lobectomy (60210). You say that supportive medical records 
to process the claim for payment are attached. The Plan denied your request. The Plan says procedure code 
60210 is not supported by the medical records submitted. 
 
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 60210 is partial thyroid lobectomy, unilateral; with or 
without isthmusectomy. 
 
  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 partial thyroid lobectomy (60210). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not document a thyroid lobectomy being performed. Therefore, this procedure cannot be 
verified. 
 
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 partial thyroid lobectomy (60210) have not been met. Therefore, we decided 
that the Plan does not have to pay for the partial thyroid lobectomy (60210) provided on March 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for PT. You say that you cannot afford the $30 copayment. The 
Plan denied your request. The Plan says the copayment was applied 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 $30 
copayment for Medicare-covered Physical Therapy in-person visits.  
 
You have been asked to pay $30 for the PT. The PT falls within the Outpatient Rehabilitation Services 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 physical therapy (PT) provided on March 24, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovenous ablation therapy of incompetent vein (36475) Stab 
phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (37765). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing the denial of the 
radiofrequency ablation procedure. The Plan denied your request. The Plan says that the records do not meet 
Medicare LCD criteria and is not reasonable and necessary and is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the surgical procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation supports that the enrollee has failed 3 months of conservative 
therapy including exercise, periodic leg elevation, weight loss, and avoidance of immobility. The enrollee is 
symptomatic and has had recurrent episodes of superficial phlebitis. 
 
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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pre-approve endovenous ablation therapy of incompetent vein (36475) Stab phlebectomy of varicose veins, 1 
extremity; 10-20 stab incisions (37765).  
 
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: Favorable

 
We decided that the Plan has to pay for a neuromuscular stimulator (E0745) provided on July 14, 2021. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met because the rented item at issue was not billed with a date range. 
 
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. Specifically, the Plan has not cited an applicable rule indicating that rented items 
of durable medical equipment must be billed with a range of dates, rather than a single date. It is the Plan's 
responsibility to substantiate its denial. In this case, the denial has not been substantiated, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for a neuromuscular stimulator (E0745) provided on 
July 14, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on February 3, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you feel you received a simple extraction 
because there was no surgery. The Plan denied your request. The Plan says this service is not covered. 
 
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 extraction covered under your dental benefit is simple 
extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) 
provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 Plan's 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 comprehensive oral evaluation (D0150) and intraoral x-rays (D0210) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided February 
28, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that this provider was listed as in-
network. The Plan denied your request. The Plan says the claim has been processed as in-network; however, 
this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond crown (D2920) provided February 28, 2022.