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

 
We decided that the Plan does not have to pre-approve gingival irrigation on tooth #5, #6, #7, and #8 (code 
D4291). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you need to have this procedure and you do 
not have the money to pay for it. The Plan denied your request. The Plan says that gingival irrigation (D4291) 
is not covered by your preventive and comprehensive 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 
gingival irrigation on tooth #5, #6, #7, and #8 (code D4291).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item exceeds your benefit 
limit. 
 
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. 
 
Review of the file shows that the enrollee previously received dentures on April 30, 2021. Five plan years had 
not passed since the enrollee last received their dentures. This means the request exceeds the enrollees benefit 
limits. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the full cast high noble metal crown. You say that your dentist recommended and 
placed this crown. You also say that the dentist's office manager said in her experience, if an insurance 
company does not cover code D2790, they will pay based on code D2792. 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. Therefore, we decided that the Plan does not have to pay for the full 
cast high noble metal crown (D2790) provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardio genomic testing coded as 81408, 81407, 81405 and 
81406 provided November 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says the records 
submitted do not support medical necessity. 
 
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 pay for the laboratory services. 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 Cardio Genomic laboratory services met, 
but did not exceed, the enrollee's medical need, and was at least as beneficial as an existing and available 
medically appropriate alternative. The testing is not considered an accepted standard of medical practice for the 
diagnosis or treatment of the enrollee's condition. It has not been demonstrated that the number of genes or tests 
in the Comprehensive Cardio Panel is reasonable and necessary to establish a diagnosis for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for cardio genomic testing coded as 81408, 81407, 81405 and 81406 provided November 
13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
spondylosis without myelopathy or radiculopathy. She presented with low back pain that is aggravated with 
bending over. There are multiple plausible pathologic sources of significant pain generation. The 
documentation is lacking reasonably detailed and/or evidenced findings supportive of the spinal vertebral 
bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The Intracept 
procedure is not reasonable or medically necessary at this time. 
 
 
 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 an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary as the enrollee needs 
her mobility to manage her diabetes and overall health. The Plan denied your request. The Plan says IRF care is 
not medically necessary and the enrollee's needs can be met at a lower level of care such as in a skilled nursing 
facility or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
Our physician reviewer found that while the enrollee has a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program such as an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear purchased on October 8, 2021. 
 
You asked the Plan to pay for the routine eyewear. You say that the items should be covered. The Plan denied 
your request. The Plan says these items are not covered.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained within the Plan's network. 
 
We looked at the file and the Plan's rules. Specifically, these items were purchased outside of the Plan's 
network. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine eyewear purchased on 
October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, and 81301) 
provided on October 10, 2021. 
 
You asked the Plan to pay for codes 81206, 81275, 81276, and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81275, 81276, and 81301) provided on October 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post-operative office visit (D0171), removal of torus 
mandicularis (D7473), endosteal implant (D6010), overdenture-complete mandibular (D5865), coping 
(D2975), and custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve an office visit, removal of torus, implant, overdenture, coping, and 
abutment. The Plan denied your request. The Plan says that dental codes D0171, D7473, D6010, D5865, 
D2975, and D6057 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 post-
operative office visit (D0171), removal of torus mandicularis (D7473), endosteal implant (D6010), 
overdenture-complete mandibular (D5865), coping (D2975), and custom fabricated abutment (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and surgical extraction (D7210) provided on February 2, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
surgical extraction. You say that you would like to be reimbursed for these services that you paid for. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. 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 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 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and surgical 
extraction (D7210) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of a root canal obstruction (D3331) and 
unspecified endodontic procedure (D3999). 
 
You asked the Plan to pre-approve the dental services. You say that you have been trying to get your root canal 
done since June 2021. You also say that you do not want to try to receive services from another provider. The 
Plan denied your request. The Plan says root canal obstruction and unspecified endodontic procedure are not 
listed as covered services. 
 
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 root canal obstruction 
and unspecified endodontic procedure are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve treatment of a root canal obstruction (D3331) and unspecified 
endodontic procedure (D3999).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that you are experiencing weakness in your 
lower extremities. You say that you would like to get stronger. You also say that you would like to see this 
provider as you have seen them in the past. The Plan denied your request. The Plan says there are in network 
providers that are available to provide these services. 
 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 physical therapy visits 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 8 additional physical therapy (PT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia assistant services provided on October 21, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
not eligible for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the assistant service is a physician, PA, NP, or CNS. 
Medicare only makes payment for assistant services when provided by one of these types of practitioners. 
Therefore, we decided that the Plan does not have to pay for the anesthesia assistant services provided on 
October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain crown for the enrollee (D2740).
You asked the Plan to provide coverage for these services. You say that the requested crown is medically
necessary. The Plan denied your request. The Plan says insufficient dental records were submitted to support
this service. Maximus overturned the Plans denial for a lack of Plan contract submitted with the file. The Plan
requested a reopen and provided a copy of the required Plan contract.
The Plan is correct in this case. Medicare does not cover dental benefits. The Plan covers dental services as a
supplemental benefit, with limitations. There were no dental records submitted to determine the necessity of the
requested crown, such as dental x-rays. Therefore, we decided that the Plan does not have to provide coverage
for a porcelain crown for the enrollee (D2740).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee does not have transportation. You 
also say that they cannot drive. The Plan denied your request. The Plan says additional trips beyond the 
approved 12 one-way trips per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (code D4341). 
 You asked the Plan to pre-approve the dental services. You say that the dentist x-rays were provided from 
another dentist and may not show bone loss. The Plan denied your request. The Plan says there are only a few 
areas of minimal bone less evidence. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 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 services are not medically reasonable or necessary. Our physician reviewer found the
documentation submitted, including x-ray images, does not sufficiently support that the requested deep gum 
and root cleaning in all four quadrants is reasonable and necessary for the enrollee in this case. 
 
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 deep gum and root cleaning (code D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7473, D5899) provided on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they are not a 
covered benefit under your supplemental benefit coverage. 
 
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 dental 
services (D7473, D5899) provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 9, 2021.
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 procedure code 12032 is 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 12032 is repair, intermediate, wounds of scalp, axillae,
trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm.
We find that CPT code 12032 is not supported in the medical record. Specifically, there is no documentation of
an intermediate repair of a wound on the scalp, axillae, trunk and/or extremities, excluding hands and feet, 2.6
cm to 7.5 cm. 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 pay for the surgical services rendered on June 9, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast (77049). 
 
You asked the Plan to pre-approve MRI of the breast. You say that this imaging service is medically necessary 
due to the enrollee's genetic susceptibility to malignant neoplasm of the breast. The Plan denied your request. 
The Plan says that the requested MRI is not medically necessary in this case. The breast exam provided did not 
show any abnormal findings. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRI of the breast. Our reviewer says 
that the requested service is medically necessary and reasonable in this case. Our physician reviewer found 
breast MRIs for screening for breast cancer are considered a standard of care for patients with a lifetime risk of 
greater than 20%. This enrollee meets these criteria; therefore, the service is reasonable and 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 MRI of the breast have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) of the breast (77049).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ceftriaxone sodium (J0696) provided from November 12, 
2021, to November 18, 2021. 
 You asked the Plan to pay for the ceftriaxone sodium. You say that the claim has not been paid in full or under 
the terms of the contract for the services provided to the enrollee. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the ceftriaxone sodium (J0696) 
provided from November 12, 2021, to November 18, 2021.  
 
Benefits for the ceftriaxone sodium may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.