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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341), intravenous moderate (conscious) sedation/analgesia-first 15 minutes (D9239), and 
intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute increment (D9243). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing-four or more teeth per quadrant (D4341), intravenous moderate (conscious) 
sedation/analgesia-first 15 minutes (D9239), and intravenous moderate (conscious) sedation/analgesia-each 
subsequent 15 minute increment (D9243).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 14, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when you 
got home from the hospital you felt dizzy and an ambulance was called. You also say that you received sugar to 
raise your blood pressure and there was no need to be transported back to the hospital. 
 
 The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for long term acute care hospital (LTACH)
services for the enrollee.

You asked the Plan to provide coverage for the LTACH services. You say that at the time of the appeal, these
services 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 there were not services provided in the LTACH that were not
already being provided to the enrollee at the originating facility.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that LTACH services are
covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the
enrollee. Long-term acute care hospitals are certified as acute care hospitals, and in general, do not provide
clinical services that are materially different than those of short-term acute care hospitals.

The available clinical documentation does not support that this enrollee required services at the LTACH that
were not available at the acute care hospital where he was then receiving care. Therefore, we decided that the
Plan does not have to provide coverage for long term acute care hospital (LTACH) services for the enrollee.
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 on August 3, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 3, 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 June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided 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 June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown provided on September 14, 2023. 
 
You asked the Plan to pay for the dental crown. You say that you were told that the crown was a covered 
benefit by the health Plan. The Plan denied your request. The Plan says a dental crown 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 dental crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
crown provided on September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 provided on June 26, 2023, to July 20, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide OON care. 
 
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 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 procedure code 99213 provided on June 26, 2023, 
to July 20, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Maverick Vertical Shock foot (L5986, L5987).

You asked the Plan to pre-approve a Maverick Vertical Shock foot. You say that these items are medically
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage
criteria has not been met. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that
Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met. The Plan noted that the vendor states a K3 foot is medically necessary as you are a K3 ambulator.
However, this is not consistent with available medical history. The medical records show you currently use a
power wheelchair. This is not consistent with K3 ambulation. Medicare covers items that meet, but do not
exceed, the member's need. The medical records do not show why you require a K3 foot, or why a standard
foot would not meet your needs. Therefore, the documentation does not demonstrate that you are a K3
ambulator.

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 a Maverick Vertical Shock foot have
been met. There is inconsistent information in the case file that clearly confirms you meet the required criteria
for the requested prosthetic components. Therefore, we decided that the Plan does not have to pre-approve a
Maverick Vertical Shock foot (L5986, L5987).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44120 billed for April 25, 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 the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 50543 
provided on April 20, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 44120 billed for 
April 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing procedures (81279). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested services are a necessity for your 
care. The Plan denied your request. The Plan says that rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not been able to provide information about the 
laboratory that would perform the requested services, including information about the laboratory's location. 
Without this information, we are unable to verify that the Plan used the correct rule to formulate its denial. It is 
the Plan's responsibility to support its denial. In this case, the Plan's denial is not supported, so we must find in 
your favor. Therefore, we decided that the Plan has to pre-approve genetic testing procedures (81279).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft for ridge preservation-per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation with a medicinal agent per 
quadrant (D4921 x 4) and an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that you never received the occlusal guard from 
your previous provider. 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 September 13, 2022, and 
November 20, 2023. Therefore, we decided that the Plan does not have to pre-approve the gingival irrigation 
with a medicinal agent per quadrant (D4921 x 4) and an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial mandibular denture (D5226) provided on August 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that for people who depend on Social Security 
benefits, the budget does not have room for the extra $496. 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 annual maximum benefit in excess of Medicare coverage, certain limitations 
apply. The record shows your annual maximum benefit for the requested item or service was exhausted on date 
of service August 15, 2023. Therefore, we decided that the Plan does not have to pay for partial mandibular 
denture (D5226) provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 4, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 23, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239, E2103) 
provided on July 5, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239, E2103) provided on July 5, 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 on June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing provided to the enrollee on October 4,
2022.

You asked the Plan to pay for the diagnostic testing. You say that the testing was medically necessary. The
Plan denied your request. The Plan says a panel cannot be unbundled and billed as individual components
regardless of the fact that the test reports multiple individual pathogens and/or targets. Maximus overturned the
Plan's denial. The Plan requested a reopening and stated that this was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically
necessary and used to perform the test.

We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were
used in this case. As such, a single code with one unit of service should be used. Based on this information, we
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the
Plan does not have to pay for the diagnostic testing provided to the enrollee on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an advanced knee (L5814, L5845, L5850) and
advanced foot (L5981) for a leg prosthesis for the enrollee.

You asked the Plan to provide coverage for these accessories. You say that at the time of the appeal, these
items were 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 do not describe any K3 activities the enrollee will
be doing or that cannot be accomplished with a K2 knee and foot. The records do not confirm the enrollee was
a K3 ambulator at the time of the appeal.

The Plan is correct in this case. 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. Based on the medical records provided, the
enrollee did not meet the criteria for the requested equipment as the records do not confirm K3 ability.
Therefore, we decided that the Plan does not have to provide coverage for an advanced knee (L5814, L5845,
L5850) and advanced foot (L5981) for a leg prosthesis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network providers.

You asked the Plan to provide coverage for service with an out of network provider. The Plan denied your
request. The Plan says there were network providers available to render this service. Maximus overturned the
Plans denial for insufficient information in the case file regarding network providers in your area. The Plan
requested a reopen and provided a list of network providers in your area and indicated they attempted to work
with the out of network provider to direct you back into the network.

The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. Therefore, we decided that the Plan does not have to
provide coverage for the repair of complex retinal detachment with an out-of-network (OON) provider.