Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 23, 2023, to 
October 6, 2023. 
 
You asked the Plan to pay for the acupuncture services. 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 been diagnosed with lumbago with sciatica 
unspecified side, 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 23, 2023, to October 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for extraction, erupted tooth, or exposed root 
(D7140), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate 
(conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), therapeutic parenteral drug 
(D9610), unspecified adjunctive procedure (D9999) provided on September 25, 2023. 
 
You asked the Plan to reimburse more for the dental services. You say that upfront payment is required and 
you are seeking reimbursement. 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. 
Therapeutic parenteral drug (D9610) and unspecified adjunctive procedures (D9999) are excluded from this 
benefit. Therefore, we decided that the Plan does not have to reimburse more for extraction, erupted tooth, or 
exposed root (D7140), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), 
intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), 
therapeutic parenteral drug (D9610), unspecified adjunctive procedure (D9999) provided on September 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve massage therapy . You say that the only contracted provider that took your 
insurance does not provide deep tissue or cupping. You also say that you received this provider's services 4 
times, and it did not provide the medical relief that you need. The Plan denied your request. The Plan says the 
service sought or obtained by the member was or will be rendered by a provider who is not under contract with 
the Medicare Health Plan. 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network 
provider.
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 8, 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 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lap belt (E0978). 
 
You asked the Plan to pre-approve a lap belt. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says a lap belt is already included with the power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a lap belt is included in the payment of a power 
wheelchair. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a lap belt have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
lap belt (E0978).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that receiving the dental services benefited your oral 
health and you were in pain. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the limited oral evaluation and the intraoral radiographic image 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 limited 
oral evaluation (D0140) and the intraoral radiographic image (D0220) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), comprehensive oral evaluation 
(D0150), intraoral-comprehensive series of radiographic images (D0210), resin-based composite-two surfaces, 
anterior (D2331), resin-based composite-three surfaces, anterior (D2332), and the resin-based composite-one 
surface, posterior (D2391) provided on September 27, 2023. 
 
You asked the Plan to pay for the items/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 items/services provided in this case are not 
covered by Medicare or the Plan.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  
The items/services you are asking the Plan to pay for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental items/services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental 
cleaning (D1110), comprehensive oral evaluation (D0150), intraoral-comprehensive series of radiographic 
images (D0210), resin-based composite-two surfaces, anterior (D2331), resin-based composite-three surfaces, 
anterior (D2332), and the resin-based composite-one surface, posterior (D2391) provided on September 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D5120) on August 3, 2023. 
 
You asked the Plan to pay for the dental service (D5120). You say that you would like to request 
reconsideration for payment. 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 January 27, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental service (D5120) on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020), bifocal lenses (V2200), anti-reflective 
coating (V2750) and polycarbonate lenses (V2784). 
 
You asked the Plan to pre-approve frames (V2020), bifocal lenses (V2200), anti-reflective coating (V2750) and 
polycarbonate lenses (V2784). You say that you lost your glasses somewhere and need them replaced. The 
Plan denied your request. The Plan says the benefit for the requested services has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $400 for one set of eyewear per year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the eyewear benefit is limited to a one time 
use per year. The record shows this benefit was exhausted on July 12, 2023. Please note, that you may wish to 
submit a new request for coverage under your 2024 benefits. Based on this information, we decided that the 
Plan's rules for coverage of frames (V2020), bifocal lenses (V2200), anti-reflective coating (V2750) and 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pre-
approve frames (V2020), bifocal lenses (V2200), anti-reflective coating (V2750) and polycarbonate lenses 
(V2784).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 21, 2023, 
to February 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that you are requesting reimbursement for the 
services that were paid. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. Also, the services rendered were not urgent or emergent. 
 
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 the home health services provided from February 
21, 2023, to February 28, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration, of natural teeth-non-
resorbable barrier, per site (D4267 x 2) and bone replacement grafts for ridge preservation-per site (D7953 x 2). 
 
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 guided tissue regeneration, of natural teeth-
non-resorbable barrier, per site (D4267 x 2) and bone replacement grafts for ridge preservation-per site  
(D7953 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 14, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that your provider scheduled the appointment and 
refraction. You also say if you had known there was an option to wait, you would have waited. The Plan denied 
your request. The Plan says the refraction benefit maximum for this benefit period has been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to one refraction every calendar year. 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you had a previous refraction on March 17, 
2023, which processed by the Plan to pay 100% per the benefits. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction (92015) provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) provided on 
August 9, 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 this service is not a covered benefit.  
 
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 x-ray exam of the cervical spine (72040) provided on August 9, 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 13, 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 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified diagnostic procedure (D0999) provided on 
September 21, 2023. 
 
You asked the Plan to pay for D0999. You say that you had no control over what services the dentist provided. 
The Plan denied your request. The Plan says the denied 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 pay for an 
unspecified diagnostic procedure (D0999) provided on September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), frames (V2020), 
polycarbonate (V2784), spherocylinder bifocal lens (V2203), and sphere, bifocal lenses (V2200) provided on 
August 23, 2023. 
 
You asked the Plan to pay for anti-reflective coating, frames, polycarbonate, spherocylinder bifocal lens, and 
sphere, bifocal lenses. You say that you have used this provider for several years and never had a problem. You 
also say your allotment is $250 and I paid the additional money for frames. The Plan denied your request. The 
Plan says the maximum benefit has been exceeded. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $250 allowance for either eyeglasses or contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers eyeglasses and frames or 
contact lenses up to the Plan allowance amount. The record shows you already had a contact lens fitting on 
June 29, 2023. Therefore, the remainder of the eyewear allowance must be used on contact lenses. Based on 
this information, we decided that the Plan's rules for coverage of anti-reflective coating, frames, polycarbonate, 
spherocylinder bifocal lens, and sphere, bifocal lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for anti-reflective coating (V2750), frames (V2020), polycarbonate (V2784), 
spherocylinder bifocal lens (V2203), and sphere, bifocal lenses (V2200) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May
3, 2023.

You asked the Plan to pay for the panoramic radiographic image. 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 requested item or service has already been exhausted. Maximus overturned the Plan's denial based on lack
of information. The Plan requested a reopening and stated that you have met the benefit limit for these services.
The Plan is correct 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 11, 2022. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic
image (D0330) provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 14, 2023, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 14, 2023, billed with 
code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Lite continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that this CGM is medically necessary. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Lite continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 5, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have included all the correct documentation. 
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. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on July 5, 2023.