Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative Gel-One injections. 
 You asked the Plan to pre-approve Hyaluronan or derivative Gel-One injections. You say that you need the 
injection to improve your mobility. The Plan denied your request. The Plan says the requested drug does not 
meet the step-therapy requirements for approval. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyaluronan or derivative Gel-One 
injections. Our reviewer says that the requested drug does not meet the criteria necessary for approval. Our 
physician reviewer found the Plan requires a trial of drugs Euflexxa, Durolane, Supartz-FX, and Gelsyn-3 
before they will approve the requested drug. The documentation provided does not show that the enrollee has 
tried and failed the Plans preferred drugs. The documentation does not support that the preferred drugs would 
likely be less effective or would likely have adverse effects 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 
Medicare rules for coverage of Hyaluronan or derivative Gel-One injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Hyaluronan or derivative Gel-One injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete lower denture (indirect) (D5751) 
provided on August 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service August 15, 2023.  
  
 
 
Specifically, the Plans contract states that one reline of a complete upper or lower denture is covered per year. 
On this day, you also received a reline of a complete upper denture which was paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for the service provided in this case. Therefore, we decided that the 
Plan does not have to pay for the reline of a complete lower denture (indirect) (D5751) provided on August 15, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120) and the extractions, 
of an erupted tooth or exposed root (elevation and/or forceps removal) for teeth number 27, 28, 29, and 32 
(D7140 x 4). 
 
You asked the Plan to pre-approve the dental items/services. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says dental items/services from an out-of-network 
provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
 
 
You are requesting dental items/services from an out-of-network provider. Though the Plan offers a dental 
benefit in excess of Medicare coverage, dental items/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 pre-approve a complete 
lower denture (D5120) and the extractions, of an erupted tooth or exposed root (elevation and/or forceps 
removal) for teeth number 27, 28, 29, and 32 (D7140 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitoring 
(CGM) system. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM system. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Freestyle Libre 3 CGM system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 3 continuous glucose monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 24, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had an infection and were in pain and you 
should not have to pay for the evaluation. 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 the Plan paid for a comprehensive periodontal evaluation (D0180) on April 5, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of April 5, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete upper denture (D5110) and to pay for the 
limited oral evaluation (D0140), the intraoral radiographic images (D0230), an extraction (D7140) for tooth 
#21, #22, #23, #24, #25 26, and #27, and the removal of torus mandibularis (D7473) provided on April 3, 2023, 
April 27, 2023, and May 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you went to the office for a referral and 
not x-rays and the procedures were medically necessary. The Plan denied your request. The Plan says your 
benefit for the limited oral evaluation, the intraoral radiographic images, and your annual dental maximum for 
the year has already been exhausted. Also, the removal of torus mandibularis is not covered by the Plan. 
 
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 the Plan paid for a limited oral evaluation (D0140) and an intraoral radiographic image (D0220) on 
April 3, 2023; therefore, your benefit for the limited oral evaluation (D0140) and intraoral radiographic images 
(D0230) was exhausted on the date of service of April 3, 2023. The records shows that the Plan paid $154 for 
dental services on April 3, 2023. On April 27, 2023, the Plan paid $1,846 for dental services. For the year of 
2023 the Plan paid $2,000 ($154 paid + $1,846 paid) for dental services; therefore, your annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of April 27, 2023. The removal of 
torus mandibularis is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not 
have to pay more for the complete upper denture (D5110) and to pay for the limited oral evaluation (D0140), 
the intraoral radiographic images (D0230), an extraction (D7140) for tooth #21, #22, #23, #24, #25 26, and 
#27, and the removal of torus mandibularis (D7473) provided on April 3, 2023, April 27, 2023, and May 18, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 18, 2022, to June 
19, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you must file claims no later than 12 months or one 
full calendar year after the date when the services were provided. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent hospital care was not filed until August 12, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care provided on June 18, 2022, to June 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the cone beam computed tomography (CT) capture 
and interpretation with field of view of both jaws; with or without cranium (D0367) provided on August 28, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation and the intraoral x-ray provided has already been exhausted. Additionally, the cone beam CT scan 
provided is not a covered benefit 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 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 limited oral evaluation and intraoral x-ray provided was exhausted on date of service 
August 24, 2023. Specifically, the Plans contract states that one limited oral evaluation and one intraoral x-ray 
are covered per year. You previously received these services on August 24, 2023, less than one year prior, 
which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services. 
Additionally, the cone beam CT scan provided in this case is not a covered benefit under the supplemental 
dental policy. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem 
focused (D0140), intraoral-periapical first radiographic image (D0220), and the cone beam computed 
tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) 
provided on August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on July 5, 2023 to July 28, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you were recommended to go to this 
provider by your primary care physician. You also say because of this, the services should be covered and to 
reprocess for payment. The Plan denied your request. The Plan says there is no documentation that you have a 
qualifying wound present. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified 
with code A6545 that were issued on July 5, 2023 to July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology consultation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve neurology consultation. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization 
was not obtained. 
 
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 items/services 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 
neurology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth 
#6, #7, #8, #9, #10, #11, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #28, the removal of residual tooth 
(D7250) for tooth #3, #5, #12, #13, and #16, and the deep sedation (D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain, and you need the 
teeth to come out. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the surgical removal of erupted tooth, the removal of residual tooth, and the deep sedation are 
not covered by the Plan. 
 
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 the 
surgical removal of erupted tooth (D7210) for tooth #6, #7, #8, #9, #10, #11, #19, #20, #21, #22, #23, #24, #25, 
#26, #27, and #28, the removal of residual tooth (D7250) for tooth #3, #5, #12, #13, and #16, and the deep 
sedation (D9222 and D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and therapeutic drugs (D9612) 
provided on September 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that the Plan would cover 100% 
of the dental services. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the consultation and therapeutic drugs are not covered by the Plan. 
 
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 a 
consultation (D9310) and therapeutic drugs (D9612) provided on September 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), and panoramic radiographic image (D0330) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have been going to this dentist for 40 years. 
You also say that you have been getting new teeth for that long and prefer to go to them instead of a new 
dentist. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested 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 
the comprehensive oral evaluation - new or established patient (D0150), and panoramic radiographic image 
(D0330) provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on
November 7, 2022.

You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you do not agree
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly.
Maximus overturned the Plan's denial because of a lack of information. The Plan requested a reopening and
provided the 2022 EOC.

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 $50
copayment for Medicare-covered outpatient diagnostic tests.

You have been asked to pay a $50 copayment for the diagnostic mammogram. This item/service falls within
the Medicare-covered outpatient diagnostic tests 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 the diagnostic mammogram provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
image (D0220), a crown (D2740) for tooth #13, the prefabricated post and core (D2954) for tooth #13, a 
panoramic radiographic image (D0330), and the endodontic therapy (D3320) for tooth #13 provided by an out-
of-network provider on July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you could not find an in-network provider and 
you had a broken tooth. 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. Also, it was verified that there was 
no contact with the Plan prior to the date of 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. 
 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 limited oral evaluation (D0140), the intraoral radiographic image (D0220), a crown (D2740) for 
tooth #13, the prefabricated post and core (D2954) for tooth #13, a panoramic radiographic image (D0330), and 
the endodontic therapy (D3320) for tooth #13 provided by an out-of-network provider on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement wheelchair (K0005). 
 
You asked the Plan to pre-approve the replacement wheelchair. You say that the wheelchair is medically 
necessary. The Plan denied your request. The Plan says a replacement wheelchair is not covered at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement wheelchair (K0005).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 provided on May 22, 
2023, and May 23, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 99223 and 99233 
have been met. In this case, the evaluation and management reports do not include the enrollee's name to verify 
the billed services. Therefore, we decided that the Plan does not have to pay for procedure codes 99223 and 
99233 provided on May 22, 2023, and May 23, 2023.