Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drive wheel color insert with adhesive tape (K0108). 
 
You asked the Plan to pre-approve a drive wheel color insert with adhesive tape. The Plan denied your request. 
The Plan says this item does not serve a medical need and cannot be covered. 
 
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 drive wheel color insert with adhesive tape (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you travel a lot and need 
something that you can take with you that is light weight. The Plan denied your request. The Plan says a 
portable oxygen concentrator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and diabetic 
supplies. 
 
You asked the Plan to pre-approve a CGM and diabetic supplies. You say that this CGM is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the medical criteria for a CGM have 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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM and diabetic supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) and diabetic supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you need this CGM. The Plan denied your request. 
The Plan says the medical criteria for a CGM 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 the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the periodic oral evaluation (D0120) and 
periodontal maintenance (D4910) provided on June 6, 2023. 
 
You asked the Plan to waive the cost sharing for the dental services. You say that the cost sharing is not correct 
because you had a regular cleaning. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per visit for all non-Medicare covered services and a 50% coinsurance for each major service. 
 
You have been asked to pay a $48.50 for the dental services ($10 copayment + $38.50 coinsurance = $48.50). 
This item/service falls within the dental services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost sharing for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on June 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you fell and chipped your tooth. You also say 
you went to the dentist to have them take a look to make sure that the teeth are okay. 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 May 2, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the office visit provided on September 
27, 2023, by the out-of-network provider. 
 
You asked the Plan to reimburse the full amount for the physician service. You say that you should have been 
reimbursed $96 for this service. The Plan denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for physician/practitioner services.  
 You have been asked to pay a $0 copayment for the physician service. This service falls within the 
physician/practitioner services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The record shows that the Plan paid the full Medicare allowed amount of 
$55.98. Additionally, the Evidence of Coverage clearly states that you may pay more when you see an out-of-
network provider. Therefore, we decided that the Plan does not have to reimburse any additional amount for the 
office visit provided on September 27, 2023, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided by an out-of-network provider on September 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider did not validate on their end that 
they were not in-network. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by the enrollee's 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 the enrollee 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 periodic oral evaluation (D0120) and a cleaning (D1110) provided by an out-of-network 
provider on September 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (PWC). 
 
You asked the Plan to pre-approve a replacement PWC. You say that your previous chairs have lasted much 
longer. You say that your current PWC scratches you and leaves scars. You also say that you use this chair 
daily and is causing issues getting to appointments and hindering care. The Plan denied your request. The Plan 
says your current PWC is less than 5 years old. The Plan also says that the notes do not show that your current 
PWC is broken and cannot be fixed or that your condition has changed in a way that makes a new or different 
one necessary. 
 
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 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377) with harness
(E2313) and electronic connection (E2311) for the enrollee.

You asked the Plan to provide coverage for the requested upgraded electronics. You say that at the time of the
appeal, the requested upgraded electronics were medically necessary. The Plan denied your request. The Plan
says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the medical records show
that at the time of the appeal, the enrollee had adequate strength to operate the switches that come with the
approved power wheelchair and did not require the upgraded electronics.

The Plan is correct in this case. The available clinical documentation in the case file does not support that the
requested upgraded electronics were medically reasonable and necessary for the enrollee in this case.
Therefore, we decided that the Plan does not have to provide coverage for an expandable controller (E2377)
with harness (E2313) and electronic connection (E2311) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care, per day 
(99233) provided on February 11, 2022. 
 
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 the service is not payable as a corrected claim 
was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that a corrected claim must be submitted within one year from 
the date of the initial determination or redetermination for any reason. 
 
The record shows that a corrected claim for this service was not filed until August 4, 2023. This means that 
more than one calendar year from the date of service had passed before a corrected claim was filed.   
 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital inpatient or observation 
care, per day (99233) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0274, D1110, and D0120) on August 
24, 2023. 
 
You asked the Plan to pay for the dental services (D0274, D1110, and D0120). You say that you would like to 
request reconsideration for payment. 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 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 the dental services (D0274, D1110, and D0120) on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99213) on 
September 20, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this chiropractic service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor (99213) on September 20, 2023.
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 July 11, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
required documents and you 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 July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that the previous chair being replaced was approved as medically necessary by the Plan. The enrollee needs the new chair requested. The Plan denied your request. The Plan says the enrollee 
meets criteria for a Group 3 power wheelchair base; however, does not meet criteria for tilt features and 
therefore does not meet criteria for base code power wheelchair group 3 with a single power option. 
 
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 an electronic connection between 
wheelchair controller and one power seating system motor. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found that the 
requested item is not medically necessary in this case, as the enrollee does not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. 
 
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 electronic connection between wheelchair controller and one power seating 
system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) for teeth #2, #3, #4, 
#5, #12, #13, #14 and #15. 
 
You asked the Plan to pre-approve D6056. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service 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 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 a 
prefabricated abutment (D6056) for teeth #2, #3, #4, #5, #12, #13, #14 and #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin based composite of three posterior surfaces (D2393) 
provided on September 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that your previous provider passed away. You also 
said you had an emergency appointment for pain. 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 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 resin based composite of three posterior surfaces (D2393) provided on September 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture (D5213), unspecified preventive 
procedure (D1999) and invalid procedure code (N4109) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that it is requested that the claim for payment for 
work legally and officially performed by the providing dentist as listed in said claim be reviewed. The Plan 
denied your request. The Plan says your benefit for maxillary partial denture (D5213)  has already been 
exhausted. The Plan also says that unspecified preventive procedure (D1999) and invalid procedure code 
(N4109) are 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 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 maxillary partial denture (D5213) was exhausted on date of service March 4, 2023. 
Unspecified preventive procedure (D1999) and invalid procedure code (N4109) are excluded from this benefit. 
Therefore, we decided that the Plan does not have to pay for maxillary partial denture (D5213), unspecified 
preventive procedure (D1999) and invalid procedure code (N4109) provided on July 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
24, 2023. 
 
You asked the Plan to pay for the ED services. You say that the claim got denied due to ineligible to bill 
Medicare and you would like the claim to be processed. The Plan denied your request. The Plan says Medicare 
payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Inogen portable concentrator and equipment purchased 
on April 19, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you paid out-of-pocket so that you didn't 
have to carry the tanks along everywhere. You also say that you need to be on CO2, the portable lasts a lot 
longer and when you go to the store it is inconvenient to carry the tanks around. The Plan denied your request. 
The Plan says coverage of this item is only considered when the DME item is rented. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the Inogen portable concentrator and equipment purchased on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 11, 2023, to 
August 29, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that there is no in-network acupuncture 
providers in Baton Rouge. You say that the closest provided is in New Orleans which is over 50 miles away. 
The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have low back pain that is unspecified, and 
acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided on August 11, 2023, to August 29, 2023.