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

We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) for
the enrollee.

You asked the Plan to pre-approve a Dexcom G7 CGM. You say that the enrollee prefers an option that does
not require scanning. The Plan denied your request. The Plan says only the preferred brand products are
covered. Maximus overturned the Plan's denial because of a lack of information. The Plan requested a
reopening and provided the Customer Handbook.

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 and Customer Handbook, the requested brand
is not a preferred brand for diabetic monitoring supplies. Therefore, we decided that the Plan does not have to
pre-approve a Dexcom G7 continuous glucose monitor (CGM) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on August 4, 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 the provider opted out of Medicare; therefore, the services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
outpatient visit provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the inserts were medically necessary to stabilize and 
support your feet and ankles and to minimize your pain. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on March 23, 
2023. 
 
You asked the Plan to pay for evaluation and management services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the claim must be filed no 
longer than the close of the period ending one calendar year after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for evaluation and management services was not filed until September 25, 2023. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for evaluation and management services provided on 
March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on June 13, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental item was received from an out-of-
network provider and is 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 dental item from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/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 
upper partial denture (D5213) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410) and retrograde filling (D3430). 
 
You asked the Plan to pre-approve the dental services. You say that your provider advised you these 
procedures are necessary to prevent an infection. The Plan denied your request. The Plan says these services 
are not covered benefits under your dental 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 pre-approve an 
apicoectomy (D3410) and retrograde filling (D3430).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service July 25, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 31 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin composites (D2332, D2331) provided on August 
23, 2023. 
 
You asked the Plan to pay for the resin composites (D2332, D2331). You say that you had to pay $385 out-of-
pocket and are appealing this denial. The Plan denied your request. The Plan says the services are not covered 
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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the resin composites (D2332, D2331) 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the resin composites (D2332, D2331) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #12 to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
service.The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve a crown 
(D2740) for tooth #12 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and to pay 
for the panoramic radiographic (D0330) and the palliative treatment (D9110) provided by an out-of-network 
provider on August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you paid the full amount for the dental 
services and would like the Plan to reimburse you. 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. Your benefit for the panoramic radiographic image has already been 
exhausted. Also, the palliative treatment 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. 
 
The total amount billed for the limited oral evaluation (D0150) was $82 and the total allowed was $46 leaving 
a difference of $46 ($82 billed - $46 allowed). 
 
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. The 
record shows the Plan paid for a panoramic radiographic image on October 26, 2022; therefore, your benefit for 
the panoramic radiographic image was exhausted on the date of service of October 26, 2022. The palliative 
treatment is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay more for the comprehensive oral evaluation (D0150) and to pay for the panoramic radiographic (D0330) 
and the palliative treatment (D9110) provided by an out-of-network provider on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 23, 2023, and 
local anesthesia in conjunction with operative or surgical procedure (D9215) provided on August 24, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
consultation (D9310) provided on August 23, 2023, and local anesthesia in conjunction with operative or 
surgical procedure (D9215) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment of dental pain-per visit (D9110), 
dental cleaning (D1110), abutment supported porcelain/ceramic crown (D6058), and the custom fabricated 
abutment-includes placement (D6057) provided from February 3, 2023, through March 1, 2023. 
 
You asked the Plan to pay for these 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 
palliative treatment of dental pain-per visit (D9110), dental cleaning (D1110), abutment supported 
porcelain/ceramic crown (D6058), and the custom fabricated abutment-includes placement (D6057) provided 
from February 3, 2023, through March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase in personal care attendant hours to 55.5 
hours. 
 
You asked the Plan to pre-approve an increase in personal care attendant hours to 55.5 hours. You say that the 
services are necessary. The Plan denied your request. The Plan says the Needs Assessment Questionnaire and 
Task/Hour Guide was done on December 13, 2023, which showed that you require 50.75 hours of care per 
week. The number of hours assessed by the most recent needs assessment was approved. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an increase in personal care attendant hours to 55.5 hours have not been met. Specifically, we find 
that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan 
does not have to pre-approve an increase in personal care attendant hours to 55.5 hours.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 26, 2023, billed with 
codes 81225, 81226, 81240, 81241, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 26, 2023, billed with codes 81225, 81226, 81240, 81241, and 81328.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative/surgical 
procedures (D9215) provided on September 7, 2023. 
 
You asked the Plan to pay for D9215. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The 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 services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for local anesthesia in conjunction 
with operative/surgical procedures (D9215) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images 
(D0230 x 2) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. 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 services provided 
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 services provided was exhausted on date of service August 9, 2023.  
  
 
Specifically, the Plans contract states that one intraoral x-ray is covered per year. On this day, you received 
three intraoral x-rays, in which one x-ray was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical additional radiographic images (D0230 x 2) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 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 July 20, 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 May 16, 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 May 16, 2023, billed with 
code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on August 18, 
2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental item was received from an out-of-
network provider and is 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 dental item from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/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 
complete lower denture (D5120) provided on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided on June 13, 
2023. 
 
You asked the Plan to pay for the crown. You say that your teeth needed the porcelain crowns as clinically 
indicated with the supporting documentation. The Plan denied your request. The Plan says this treatment is not 
covered by your 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain/ceramic (D2740) provided on June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bypass graft provided on February 11, 2023. 
 
You asked the Plan to pay for a bypass graft. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says the provider is not eligible to be paid for 
the service. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for a bypass graft provided on February 
11, 2023.