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

 
We decided that the Plan does not have to pay for custom fabricated abutment (D6057) and abutment supported 
retainer for a fixed partial denture (D6068) provided on October 5, 2022. 
 
You asked the Plan to pay for custom fabricated abutment and abutment supported retainer for a fixed partial 
denture. You say that the Plan did not reimburse for the implant work in 2022, however, tooth 13 is a charge 
for a crown. The Plan denied your request. The Plan says these services are not covered under your contract. 
 
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 custom 
fabricated abutment (D6057) and abutment supported retainer for a fixed partial denture (D6068) provided on 
October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and the 
periodontal maintenance (D4910) provided on May 15, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
the supplemental dental policy.   

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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206) and the periodontal maintenance (D4910) provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) 
and the alveoloplasties in conjunction with extractions-four or more teeth or tooth spaces, per quadrant  
(D7310 x 2) provided on May 19, 2023.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
the supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230) and the alveoloplasties in conjunction with extractions-four or 
more teeth or tooth spaces, per quadrant (D7310 x 2) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated abutments - includes modification and 
placement tooth #'s 11 and 13 (D6056). 
 
You asked the Plan to pre-approve the prefabricated abutments tooth #'s 11 and 13. The Plan denied your 
request. The Plan says your benefit for the requested service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on the appealed claim. Therefore, we decided that 
the Plan does not have to pre-approve the prefabricated abutments - includes modification and placement tooth 
#'s 11 and 13 (D6056).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom back cushion with hardware and a push 
handle. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom back cushion and hardware are 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 custom back cushion and hardware are not medically necessary. Our physician reviewer found the enrollee 
has cerebral palsy and impaired positioning. There is no report indicating that a customized back cushion is 
necessary for the enrollee as opposed to a prefabricated cushion. The records do not support that the criteria for 
coverage are met; therefore, the custom back cushion and hardware are not 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.  
 
The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same 
purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The file shows that the requested push handle serves the same purpose as the approved power wheelchair. A 
push handle is not needed for the powered wheelchairs movement. 
 
Therefore, we decided that the Plan does not have to pre-approve a custom back cushion with hardware and a 
push handle.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service September 
21, 2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 83789 is a column II code to column I code G0480. While code 
83789 was billed with modifier -59, the medical records provided do not show that the service billed with the -
59 modifier is a distinct procedural service. 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 83789 billed for date of 
service September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
for tooth 9. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation for tooth 9. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says this 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 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 pre-approve bone 
replacement graft for ridge preservation (D7953) for tooth 9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
15, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Navy military patch, and ice blue matte cover. 
 
You asked the Plan to pre-approve the patch and cover. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says these items do not serve a primarily medical purpose. 
 
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 Navy military patch, and ice blue matte cover.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 11, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder. 
 
You asked the Plan to pre-approve the cup holder. You say that the enrollee needs a new wheelchair. You also 
say that the enrollee is solely reliable on a wheelchair. The Plan denied your request. The Plan says this item 
does not serve a primarily medical purpose. 
 
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 cup holder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic retainer crown (D6740) for tooth 
number 9. 
 
You asked the Plan to pre-approve a porcelain or ceramic retainer crown. You say that the replacement of 
bridge from teeth 10 to 14 is needed to restore occlusion and masticatory function. The Plan denied your 
request. The Plan says the requested service is not covered when it is related to splinting teeth, including 
multiple abutments, or any service to stabilize periodontally weakened teeth. 
 
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 pre-approve a 
porcelain or ceramic retainer crown (D6740) for tooth number 9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 16, 2024, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 16, 2024, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from January 
16, 2024, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of January 16, 2024, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond January 16, 2024, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 16, 2024, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 16, 
2024, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for procedure code G0452. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code G0452 is bundled into 
payment for code 81445. 
 
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 G0452 
is a column II code to column I code 81445. This claim has not been billed with an appropriate modifier to 
bypass the edit as the 59 modifier is not supported. 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 G0452 billed 
for date of service May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided April 26, 2023, to May 18, 2023.

You asked the Plan to pay for a pneumatic compression device. You say that you are requesting reconsideration based on medical necessity for this enrollee and evidence based medical literature that substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says a PCD coded as E0675 is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided April 26, 2023, to May 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomographic (CT) colonography, screening,
including image postprocessing (74263) provided to the enrollee on February 8, 2023.

You asked the Plan to pay for the computed tomographic (CT) colonography. You say that the virtual
colonoscopy screening, including image postprocessing was medically necessary. The Plan denied your
request. The Plan says that this is not covered by Medicare. Maximus overturned the Plan's denial based on
medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

We find that procedure code 74263 has a Status Indicator of N on the Physician Fee Schedule. This means that
procedure code 74263 is not a covered service. Based on this information, we decided that Medicare rules for
coverage of the computed tomographic (CT) colonography have not been met. Therefore, we decided that the
Plan does not have to pay for the computed tomographic (CT) colonography, screening, including image
postprocessing (74263) provided to the enrollee on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home ultraviolet light therapy system.

You asked the Plan to provide coverage for a home ultraviolet light therapy system. You say that this
equipment is medically necessary. The Plan denied your request. The Plan says the enrollee has cutaneious T
cell lymphoma and a history of melanoma and does not meet the criteria for coverage. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that home ultraviolet
light therapy equipment is covered for selected patients with generalized intractable psoriasis whose medical
record documentation shows they are unable to receive this treatment outside of the home. Based on the
medical records provided, the enrollee does not have intractable psoriasis and there is no indication the enrollee
is unable to leave their home. Medicare rules for coverage of this equipment have not been met. While the use
of this equipment may be beneficial in some opinions for the enrollee's condition, it is not a condition for
which Medicare covers this equipment. Therefore, we decided that the Plan does not have to provide coverage
for a home ultraviolet light therapy system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 7, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service August 7, 
2023, and August 21, 2023. 
 
You asked the Plan to pay for procedure code S9338. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service August 7, 2023, and August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3330) and the amalgam 
(D2140) provided on August 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you called the Plan and were told that the 
claim would pay at %100. 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 the endodontic therapy (D3330) and the 
amalgam (D2140) provided on August 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services billed with codes 95938-TC, 98561-TC, 
and 95940 for July 24, 2023. 
 
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 technical component payment is not separately made to hospital outpatients. 
 
The Plan must follow Medicare rules. The rules say that radiology and other diagnostic services furnished to 
hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital.  
 
We looked at the file and Medicare rules. The file shows that the billed procedure codes were rendered to a 
hospital outpatient and payment is included in the payment to the hospital. Therefore, we decided that the Plan 
does not have to pay for the testing services billed with codes 95938-TC, 98561-TC, and 95940 for July 24, 
2023.