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

 
We decided that the Plan does not have to pay for the custom fabricated abutmentsincludes placement  
(D6057 x 2) and the implant supported porcelain/ceramic crowns (D6065 x 2) provided on August 30, 2023. 
 
You asked the Plan to pay for these dental items. 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 items provided 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 items provided are not among those 
covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutmentsincludes 
placement (D6057 x 2) and the implant supported porcelain/ceramic crowns (D6065 x 2) provided on  
August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as you disagree 
with the denial. 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 pre-approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) scan (D0364). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CT) scan (D0364).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (E2103). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the item denied correctly as the enrollee 
does not meet the clinical requirements to be approved. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (E2103).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with extractions  
one to three teeth or tooth spaces (code D7321). 
 
You asked the Plan to pre-approve an alveoloplasty not in conjunction with extractions  one to three teeth or 
tooth spaces. You say that the services are medically necessary.  The Plan denied your request. The Plan says 
an alveoloplasty not in conjunction with extractions  one to three teeth or tooth spaces is not a covered dental 
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
alveoloplasty not in conjunction with extractions  one to three teeth or tooth spaces (code D7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns-porcelain fused to high noble metal (D2750 x 2) 
provided on September 6, 2023. 
 
You asked the Plan to pay for the dental items. 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 items 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 dental items 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 
crowns-porcelain fused to high noble metal (D2750 x 2) provided on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and the related supply 
allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that you are appealing the 
denied CGM. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that specifically, the Plan did not collect medical records from their 
participating provider who ordered the requested CGM. Participating providers are considered agents of the 
Plan. Without this necessary documentation we are unable to make a determination as to whether the enrollee 
has met the criteria for coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a 
continuous glucose monitor (CGM) and the related supply allowance.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve audiology consultations and treatment to be provided by 
an OON provider.  
 
You asked the Plan to pre-approve audiology consultations and treatment. You say that you have anxiety with 
having your face touched. You also say you know and trust the owners. The Plan denied your request. The Plan 
says you must receive you care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve audiology consultations and treatment to be 
provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an awful toothache so the dentist took 
x-rays and examined your tooth. You also say that the tooth was infected, the evaluation was needed to find out 
what was wrong and you should not have to pay $151.06. The Plan denied your request. The Plan says your 
benefit for the requested services 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 services was exhausted on date of service April 28, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on September 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine transportation provided on July 21, 2023, and 
August 28, 2023. 
 You asked the Plan to pay for the routine transportation. You say that you needed routine transport on the days 
in question. The Plan denied your request. The Plan says that the services provided on July 21, 2023, and 
August 28, 2023, did not meet the criteria for routine transportation. 
 
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 routine transportation when the Plan covers routine transportation when it is scheduled at 
least 48 hours in advance through the Plan's transportation vendor.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The record shows that the 
transportation trips were not scheduled 48 hours in advance. Therefore, we decided that the Plan does not have 
to pay for the routine transportation provided on July 21, 2023, and August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a distal transcutaneous electrical nerve stimulator 
(Nerivio device). 
 
You asked the Plan to pre-approve a Nerivio device. You say that the requested Nerivio device is medically 
necessary. The Plan denied your request. The Plan says a Nerivio device is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that DME is equipment that has an expected life of at least 
3 years.  
 
We looked at the file and Medicare rules. At this time, a distal transcutaneous electrical nerve stimulator that 
stimulates peripheral nerves of the upper arm (coded as K1023 or A4540) does not meet the minimum lifetime 
requirement of at least three years. According to the Nerivio user manual, when there are no more treatments 
left, the device should be disposed. DME is a benefit for rental of equipment for use in the home and therefore 
DME items must be able to withstand repeated use by successive patients in accordance with Medicare 
regulations. Therefore, we decided that the Plan does not have to pre-approve a distal transcutaneous electrical 
nerve stimulator (Nerivio device).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J3490, 90999, J1200, A4657 provided on 
July 10, 2023, to July 31, 2023. 
 
You asked the Plan to pay for procedure codes J3490, 90999, J1200, A4657. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that certain laboratory services, drugs and 
biologicals, equipment, and supplies are subject to consolidated billing and are no longer separately payable 
when provided to ESRD beneficiaries 
 
We looked at the file and Medicare rules. The billed codes are bundled in payment for the ESRD services and 
are not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes J3490, 90999, J1200, A4657 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes J3490, 90999, J1200, A4657 provided on July 10, 2023, to July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic compression 
device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was initially evaluated on 7/27/2023 and was referred to lymphedema clinic. There is a 
lack of objective documentation and measurements that the enrollee has failed conservative treatment. There is also a lack of medical literature indicating that the requested Koya Dayspring Device non-pneumatic 
compression device is clinically as or more efficacious than standard pneumatic compression devices. The 
medical literature largely includes pilot studies with a small number of participants. Therefore, the requested 
Koya Dayspring Device non-pneumatic compression device cannot be considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Koya Dayspring non-pneumatic compression device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023, to August 14, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that there were no in-network providers in the 
patient's geographic area. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023, to August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 24, 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 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 or current physician order or relevant medical records which support 
medical necessity for the supplies provided in this case. The records received are older than 6 months old. 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 a continuous glucose monitor (CGM) (A4239) 
provided on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis,
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion
feature, (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature
(L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control
feature, swing and stance phase, includes electronic sensor(s) (L5856) for the enrollee.

You asked the Plan to pre-approve these items. You say that you disagree with the denial. The Plan denied your
request. The Plan says that the request for a K3 foot and microprocessor knee does not meet Medicare criteria
as reasonable and necessary. Maximus overturned the Plan's denial. The Plan requested a reopening and stated
that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met. The Plan noted that you state a K3 prosthesis is medically necessary as the enrollee is a K3
ambulator. However, this is not consistent with available medical history. The medical records show the
enrollee currently uses a walker for ambulation. This is not consistent with K3 ambulation. Medicare covers
items that meet, but do not exceed, the member's need. The medical records do not show why the enrollee
requires a K3 prosthetic. Therefore, the documentation does not demonstrate that the enrollee is a K3
ambulator.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of these items have been met. There is
inconsistent information in the case file that clearly confirms the enrollee meets the required criteria for the
requested prosthetic components. Therefore, we decided that the Plan does not have to pre-approve an addition,
endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition,
endoskeletal, knee-shin system, stance flexion feature, (L5845), an addition to endoskeletal knee-shin system,
fluid stance extension, dampening feature (L5848) and an addition to lower extremity prosthesis, endoskeletal
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s)
(L5856) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22633 billed for date of service February 15, 
2023.  
 
You asked the Plan to pay for procedure code 22633. You say that you disagree with the denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 22633 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 22633 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 22633 billed for date of service February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee.

You asked the Plan to pre-approve a CGM. You say that a CGM would help the enrollee. The Plan denied your
request. The Plan says that the medical criteria for a CGM have not been met. Maximus overturned the Plan's
denial for lack of information. The Plan requested a reopening and stated that the enrollee is not treated with
insulin and does not meet criteria for coverage. The Plan is correct in this case. 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor (CGM) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of a torus mandibularis (D7286 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 removal of a 
torus mandibularis (D7286 x 2).