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

 
We decided that the Plan has to pay for the extraction, of an erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140) provided on September 20, 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 that the service is not payable as it was 
rendered by an out-of-network provider.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for this service by a contract provider. The file does not show that the plan provided 
notice that this service would not be covered. Under Medicare rules, this means this service is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the extraction, of an erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) provided on September 20, 2023.  
 
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: 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 July 4, 2023. 
 
You asked the Plan to pay for the supply allowance for the 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 July 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a microprocessor foot (L5973) and vacuum
pump system (L5781) for a lower limb prosthesis for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. 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 notes that the
medical records do not document the need for a K3 foot. There is no documentation in the medical records to
show why a K2 foot will not meet the enrollee's functional needs.

The Plan is correct in this case. 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. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record to show the enrollee met the criteria required for this
equipment at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for
a microprocessor foot (L5973) and vacuum pump system (L5781) for a lower limb prosthesis for the enrollee.
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 19, 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 19, 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 August 8, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided 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 August 8, 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 7, 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 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot plate/bracket assembly (K0108 x2). 
 
You asked the Plan to pre-approve foot plate/bracket assembly. You say that the items are necessary. The Plan 
denied your request. The Plan says the requested items are miscoded. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that miscellaneous options, accessories, or 
replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code 
should be coded K0108.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of foot plate/bracket assembly have not been met. Therefore, we decided that the Plan does not have 
to pre-approve foot plate/bracket assembly (K0108 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral comprehensive series of x-rays (D0210) 
provided on August 3, 2023. 
 
You asked the Plan to pay for an intraoral comprehensive series of x-rays. You say that you were told by the 
office you would pay $38 for panoramic x-ray. You also say that you returned to the office to discuss the $120 
bill for panoramic x-rays. The Plan denied your request. The Plan says this 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 
intraoral comprehensive series of x-rays (D0210) provided on August 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found medical 
necessity of the requested CT of the abdomen and pelvis has not been demonstrated in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0367) provided on September 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dentist office wanted to do the scan because 
they thought you had an infection. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the cone beam is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0367) provided on September 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500, 87641, 87798, G0452, 87491, 
87496, 87529, 87532, 87563, 87591, 87481, 87651, and 87653 provided on October 5, 2023. 
 
You asked the Plan to pay for procedure codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 
87563, 87591, 87481, 87651, and 87653. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 procedure codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 
87563, 87591, 87481, 87651, and 87653 provided on October 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care before returning home. 
The Plan denied your request. The Plan says the enrollees medical condition does not require IRF services, and 
care can be provided in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 LTACH services. You say that at the time of the appeal, LTACH
services were medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee
was receiving the care required are the original facility. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted the medical
records show at the time of the appeal the enrollee was stable and improving. The enrollee was receiving
medically necessary acute and/or critical care. The enrollee did not have clinical conditions that were not able
to be treated by the current hospital, and there were no issues for which transfer to an LTACH would offer a
therapeutic advantage.

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 July 31, 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 July 31, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 50820, 38571, and 76496 provided on August 22, 
2023. 
 
You asked the Plan to pay for procedure codes 50820, 38571, and 76496. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure codes 50820, 38571, and 76496 based on Medicare criteria. The Plan based their denial 
on these codes being included in the payment for the primary procedure performed, 51999. However, codes 
50820, 38571, and 76496 do not have active National Correct Coding Initiative (NCCI) procedure-to-procedure 
(PTP) edits for these code pairs. The Plan has not provided any documentation or Medicare rules to support 
that codes 50820, 38571, and 76496 are not payable as billed. Therefore, we decided that the Plan has to pay 
for procedure codes 50820, 38571, and 76496 provided on August 22, 2023.  
 
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: 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 provided all 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 July 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames and progressive, polycarbonate lenses provided 
on August 1, 2023. 
 
You asked the Plan to reimburse for frames and progressive, polycarbonate lenses. You say that you self-paid 
for your lenses from the provider for $190 and your frames for $119. You also say you simply would like 
reimbursement for both the lenses and frames covered under your policy. The Plan denied your request. The 
Plan says this benefit 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 $300 per year for routine prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $300 allowance per year for routine 
prescription eyewear. You are responsible for any amount above the coverage limit. The record shows this 
benefit was exhausted with this date of service. Based on this information, we decided that the Plan's rules for 
coverage of frames and progressive, polycarbonate lenses have not been met. Therefore, we decided that the 
Plan does not have to reimburse for frames and progressive, polycarbonate lenses provided on August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided September 27, 2023, billed as 
87150, 87481, 87641, 87653, 87798 and 87801. 

 You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one Current Procedural Terminology (CPT) code on the claim. 
 
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 laboratory testing provided September 27, 2023, billed as 87150, 87481, 
87641, 87653, 87798 and 87801.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm (AAA) 
(76706) provided on July 7, 2023. 
 
You asked the Plan to pay for the AAA. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show that the patient has smoked at least 100 cigarettes in his 
lifetime, or other risk factors recommended by the United States Preventive Services Task Force. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who has a family history of abdominal aortic 
aneurysm, is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or is a beneficiary who 
manifests other risk factors in a beneficiary category recommended for screening by the United States 
Preventive Services Task Force regarding AAA. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AAA have not been met. Therefore, we decided that the Plan does not have to pay for the 
screening study for abdominal aortic aneurysm (AAA) (76706) provided on July 7, 2023.