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

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crown (D6065) 
and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve dental implants. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered 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. 
 
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 
implant supported porcelain/ceramic crown (D6065) and abutment supported porcelain/ceramic crown 
(D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional 28 transportation 
trips for therapy, dental, ophthalmologist/optometrist, and chiropractor visits. The Plan denied your request. 
The Plan says your benefit only allows 48 trips for this service. You have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 28 
additional routine transportation visits for your medical appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
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 vascular embolization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found use of prostatic artery embolization has not been shown to result in sustained long 
term health benefits in patients with benign prostatic hyperplasia. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate 
artery embolization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2335) for tooth #8 provided by 
an out-of-network provider on August 4, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had a dental emergency, and you were told 
you can see any dentist in your area. 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 you were told you only have coverage for in-network providers and the provider you requested 
information about was out-of-network. 
 
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 resin-based composite (D2335) for tooth #8 provided by an out-of-network provider on August 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown  porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the crown. You say that you had a crown done a year ago and needs to be 
redone to be part of the bridge. You also say that the crown is not defected or damaged, it has to be replaced to 
be part of the bridge for the neighboring tooth. The Plan denied your request. The Plan says your benefit for the 
crown  porcelain/ceramic 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 service was exhausted on date of service August 22, 2022. Therefore, we 
decided that the Plan does not have to pre-approve the crown  porcelain/ceramic (D2740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted molecular pathology add on procedure, Tempus
HRD cancer test (81479) provided to the enrollee on May 27, 2022.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says this testing is not
Food and Drug Administration (FDA) approved for bladder cancer. Maximus overturned the Plans denial for
medical necessity. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The
Plan noted that Maximus approved the requested Tempus HRD testing, (code 81479) because this could serve
as an "'add on' test to the Tempus xT genetic test to guide the enrollee's therapy." The Plan notes the review
did not address the fact that the Tempus HRD test does not have FDA approval or FDA clearance as a
companion in vitro diagnostic test for any cancer type, nor is it certified by the New York State Department of
Health's Clinical Laboratory Evaluation Program (CLEP) review standards.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that investigational
services are not covered. The Plan has demonstrated the test does not have FDA approval for bladder cancer.
The Medicare coverage requirements were not met for this testing. Therefore, we decided that the Plan does not
have to pay for unlisted molecular pathology add on procedure, Tempus HRD cancer test (81479) provided to
the enrollee on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology provided on June 30, 2023. 
 
You asked the Plan to pay for surgical pathology. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgical pathology 
provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the medical records provided support the need 
for the requested Dexcom G7. The Plan denied your request. The Plan says there is no medical justification as 
to why the enrollee needs to upgrade to the Dexcom G7 prior to the 5 year useful lifetime. 
 
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.  The record shows that the enrollee was approved for a Dexcom G6 on September 21, 2023 and there is no 
indication why a new device is needed. 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 Dexcom G7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that you would like to change your current Libre 2 
CGM which is not waterproof, to a Dexcom G7 device. You also say that you do summer exercises 4 days a 
week for your back and knees. The Plan denied your request. The Plan says you do not meet the coverage 
criteria for replacement. 
 
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. You asked the Plan to pre-approve the 
Dexcom G7 because it is waterproof and your Libre 2 is not. 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 
Dexcom G7.
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,
LTACH admission was 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 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 care was being provided. Medicare criteria for the requested transfer were not met.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 kit sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 kit sensor. You say that the enrollee has improved 
very slightly since last labs, A1C is now 6.0%. You also say that the enrollee does report a very healthy diet 
and frequent exercise but is still not able to decrease her blood sugar. The Plan denied your request. The Plan 
says a CGM is not covered under Medicare if the enrollee is not on insulin, or does not have documentation of 
recurrent problematic hypoglycemia. 
 
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 the FreeStyle Libre 2 kit sensor 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 kit 
sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient office services provided on July 18, 2023, to July 
25, 2023. 
 
You asked the Plan to pay for inpatient office services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient office services 
provided on July 18, 2023, to July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry care provided on August 16, 2023. 
 
You asked the Plan to pay for podiatry care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says per Medicare guidelines, routine foot care is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
podiatry care have not been met. Therefore, we decided that the Plan does not have to pay for podiatry care 
provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341) and to 
pay for an extraction (D7210) for tooth #14 provided on September 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the Plan would cover 
the dental services and you were not told you would go over your annual limit. The Plan denied your request. 
The Plan says your annual dental maximum benefit for the year 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 $737 for dental services on September 15, 2023. On September 20, 2023, the Plan paid 
$263 for dental services. For the year of 2023 the Plan paid $1,000 ($737 paid + $263 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
September 20, 2023. Therefore, we decided that the Plan does not have to pay more for the periodontal scaling 
and root planing (D4341) and to pay for an extraction (D7210) for tooth #14 provided on September 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
procedure code 99285. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99285. Our reviewer says that the medical records do not support the billing of procedure code 99285. Our reviewer found the enrollee presented to the 
emergency department (ED) with right neck pain with workup revealing normal labs, imaging showing cervical 
spondylosis, and was diagnosed with muscle spasm and cervical radiculopathy. She had stable vitals. She was 
sent home to follow-up with a neurologist. Although the documentation from this encounter supported an 
appropriate history and examination, it does not support a high level of medical decision-making to justify the 
code, 99285 as the enrollee was stable and uncomplicated.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the 30 additional trips for your 
radiation appointments. You also say that you daughter will be taking you the first few times but after that you 
have no one who can stay with you and transport you to your appointments every day. The Plan denied your 
request. The Plan says you have 5 remaining trips available on your plan and that the 25 additional requested 
trips are denied.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 30 
additional routine transportation trips for your radiation appointments. The record shows you have 5 remaining 
trips available on your plan, therefore the 25 trips exceed the benefit allowance. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on June 13, 2023. 
 
You asked the Plan to pay for an outpatient visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient visit 
provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cleaning 
(D1110) provided by an out-of-network provider on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist, and you were not aware 
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 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 a comprehensive oral evaluation (D0150) and a cleaning (D1110) provided by an out-of-network 
provider on August 29, 2023.