Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 24, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
as billed. The Plan denied your request. The Plan says that the code used to report the services provided is not 
supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
drugs from 19 drug classes were tested in this case. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on October 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 13, 2022, to June 27, 
2022. 
 
You asked the Plan to pay for the home health services.. You say that we respectfully request that all the 
detailed information be considered, and the claim be reprocessed for full payment. The Plan denied your 
request. The Plan says the claim was billed with $0 in charges on all line items. The Plan processed and 
approved the claim. Since no charges were billed, no payment is due. 
 
Maximus provides independent review for coverage disputes between Plans and enrollees. A coverage dispute 
is one in which the Plan does not pay for or approve an item or service because it believes that the item or 
service is not covered by Medicare and is not covered as an additional benefit under the terms of the Plans 
Evidence of Coverage. A non-contract provider who has been denied payment may appeal to the Plan if the 
provider executes a waiver of liability. 
 
The case file shows that the services in dispute were billed with a $0 charge for each line of service. The Plan 
has not issued a denial of the services. If you wish to bill the services in dispute with a different dollar amount 
due, you would need to submit a corrected claim to the Plan directly. A claim processing dispute is one in 
which the Plan agrees that the service is covered, but the amount of payment is in dispute.  
 We have looked at your request and have determined it is a claim processing dispute rather than a coverage 
dispute. Maximus does not have jurisdiction over these issues. You may contact the Chicago CMS Regional 
Office at 312-353-7180 with any questions you have about this dispute. Therefore, we decided that the Plan 
does not have to pay for home health services provided on June 13, 2022, to June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 27, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that this office visit should be covered as in-network. The 
Plan denied your request. The Plan says that this service is not covered when received by an out-of-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract also says that the POS benefit does not apply 
to an out-of-network office visit. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 27, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single unit crowns (D0658) for teeth #9 and #11. 
 
You asked the Plan to pre-approve single unit crowns. You say that this is medically necessary. The Plan 
denied your request. The Plan says single unit crowns (D0658) for teeth #9 and #11 are not appropriate to 
support a fixed partial bridge. 
 
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 single unit 
crowns 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 single unit crowns. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation submitted indicates that implant bodies are in place in areas 5, 6, 11 and 12 and there are no other teeth in the maxillary 
arch except for impacted third molars (#'s 1 and 16). There was no indication of the type of appliance to be 
used to replace the missing teeth. A complete treatment plan is required describing teeth being replaced and if a 
fixed appliance with pontics or an implant supported removable prosthesis is planned. 
 
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 single unit crowns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve single unit crowns (D0658) for teeth #9 and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case, the records do not show that you have a concordant history, 
physical examination, and radiologic imaging demonstrating cervical radiculopathy. The review has 
determined that the requested epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter, supplies and accessories. 
 
You asked the Plan to pre-approve the Dexcom G6 transmitter, supplies and accessories. You say that you don't 
understand why you are being denied as you have been pricking yourself for 27 years. You also say that you 
don't find it logical that it was denied due to not using insulin 3 times a day, and you find this to be too much 
for you.  The Plan denied your request. The Plan says you do 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom 
G6 transmitter, supplies and accessories have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 transmitter, supplies and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support provided on 
November 9, 2021. 
 
You asked the Plan to pay for the ambulance service. The Plan denied your request. The Plan says based on the 
information received the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this service includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized 
diagnostic or therapeutic services not available at the facility where the patient is an inpatient. 
 
 We looked at the file and Medicare rules. The enrollee was a hospital inpatient at the time of service and was 
transported to a separate facility for testing which means this ambulance service is included in the inpatient 
payment and is not separately paid by Medicare. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance service, advanced life support provided on November 9, 2021.
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 your mother needs to be placed in the rehabilitation 
facility. The Plan denied your request. The Plan says your mother's records do not show that you have complex 
rehabilitation needs. Services needed may be provided safely in a lower level of care. 
 
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 the complexity of your mother's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pre-approve pontics (D6245) for tooth #3, #4, #5, and #8 and 
retainer crowns (D6740) for tooth #2, #6, #7, #9, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says there was no documentation that the 
enrollee is unable to wear a partial denture or that they need a fixed partial bridge to eat. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the bridge is not medically necessary. Our physician reviewer found that the abutment teeth #6 and 7 are 
heavily broken down to near both the clinical attachment as well as the pulp of the teeth. It is likely that teeth 
#6 and #7 would require endodontic treatment prior to the bridge fabrication, and this should be evaluated. The 
limited amount of remaining structure would also necessitate a core buildup on teeth #6 and #7 to help stabilize 
the units within the proposed bridge. Given the unclear status of teeth #6 and #7 there would be no medical 
necessity at this time. The enrollee is missing teeth #3, #4, #5, and #8 on the right upper arch and teeth #14 and 
#16 on the left upper arch. Given there is no indication of any limitations on the part of the enrollee regarding 
the ability to wear a removable appliance. 
 
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 pontics (D6245) for tooth #3, #4, #5, and #8 and retainer crowns (D6740) for tooth #2, 
#6, #7, #9, and #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial of payment 
for dental pre-determination for dentures due to you feel that it should be paid. 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 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 exhausted on date of service April 1, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953), semi-precision 
abutment (D6191), semi-precision attachment (D6192) and surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve bone replacement, implants, and placement. You say that these should be 
covered. The Plan denied your request. The Plan says these are not covered 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 bone 
replacement graft (D7953), semi-precision abutment (D6191), semi-precision attachment (D6192) and surgical 
placement of implant body (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve D6245(tooth #10)-pontic - porcelain/ceramic and 
D6740(tooth #11)-retainer crown. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 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 exhausted. Therefore, we decided that the Plan does 
not have to pre-approve D6245(tooth #10)-pontic - porcelain/ceramic and D6740(tooth #11)-retainer crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120) 
and prophylaxis - adult (D1110) provided on January 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are asking for reimbursement for 
services billed on January 5, 2023. 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 periodic oral evaluation - established patient 
(D0120) and prophylaxis - adult (D1110) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve D6245 (tooths 5, 9) pontic - porcelain/ceramic, and 
D6740 (tooth 11) retainer crown - porcelain/ceramic. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 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 exhausted. Therefore, we decided that the Plan does 
not have to pre-approve D6245 (tooths 5, 9) pontic - porcelain/ceramic, and D6740 (tooth 11) retainer crown - 
porcelain/ceramic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Receiver. 
 
You asked the Plan to pre-approve the Dexcom G6 Receiver. 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 Receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6 Receiver.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the tooth is bad under the original crown, 
and you need it taken off to get it fixed and then a new one put back on. The Plan denied your request. The 
Plan says it is within 5 years of the initial replacement, so this 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 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 exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy re-evaluation provided on November 17, 
2022, by an OON provider. 
 
You asked the Plan to pay for the re-evaluation. You say that you are requesting reconsideration of the denied 
physical therapy re-evaluation. The Plan denied your request. The Plan says that this service 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 Plan contract also says that the enrollees POS benefit does 
not apply to physical therapy services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physical therapy re-evaluation provided on 
November 17, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray. filling, and endodontic therapy (D0220, 
D2332, D3310) provided on November 30, 2022, to December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 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 exhausted on date of service June 6, 2022 (D0220), 
December 13, 2022 (D2332), and December 21, 2022 (D3310). Therefore, we decided that the Plan does not 
have to pay for an intraoral x-ray. filling, and endodontic therapy (D0220, D2332, D3310) provided on 
November 30, 2022, to December 21, 2022.