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

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure (D4999) provided on 
July 25, 2023. 
 
You asked the Plan to pay for 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 pay for an 
unspecified periodontal procedure (D4999) provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 8, 2023. 
 
You asked the Plan to pay for dental services. You say that you were not aware the 120-day submission 
requirement applied, and the claim should be reconsidered. The Plan denied your request. The Plan says the 
claim was not submitted for reimbursement within 120 days. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of dental services have not been met. Specifically, the claim was not submitted within 120-days. 
Therefore, we decided that the Plan does not have to pay for dental services provided on March 8, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 15, 2023.  
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH level which the enrollee requires that 
are not available at the acute care setting being offered by the Plan. Given there are offered alternatives, an 
LTACH admission is not 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair repairs. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the cost of requested repairs appears to exceed the cost of replacement 
of the wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs cannot be covered if the cost of repair is 
more than the cost of replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3320) August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing 
amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3320) August 15, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
on April 27, 2023, through May 9, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218) provided on April 27, 2023, through 
May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment provided on 
August 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you feel the trip by 
ambulance was not necessary and you were not informed about needing emergency level care. You also say you did not receive any life support or emergency treatment while being transported. The Plan denied your 
request. The Plan says you are responsible for the full billed amount of this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the ambulance 
response and treatment provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
  You asked the Plan to pre-approve the injection. You say that you keep going to the hospital to get help with 
walking. You say that your legs drag which is why you cannot walk, and the injection is to help with the pain. 
The Plan denied your request. The Plan says that an epidural steroid injection 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 the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that there is no history of a 
physical examination, concordant radiological image-based diagnostic testing supporting lumbar radiculopathy, 
radicular pain, or claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative 
disc disease, producing foraminal or central spinal stenosis or post-laminectomy syndrome. Therefore, the 
enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on July 27, 2023. 
 
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 3, 2023, to August 
15, 2023. 
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that the provider opted out of Medicare. 
 
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 physician 
services provided on August 3, 2023, to August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 30, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that Medicare does not cover behavior health services 
performed by a mental health counselor. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Mental Health Counselor is 
among the provider types that are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22510, 22512, 22513, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the enrollee has any fractures in the thoracic or cervical region 
and no documentation of cervical or thoracic fractures or imaging. The request for thoracic and cervical 
vertebroplasty is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found detailed diagnostic imaging studies 
do not support any compression fractures in the thoracic and/or cervical spine. The plan has approved the 
requested L5 kyphoplasty and the rationale is not evident for the requested cervical and thoracic kyphoplasty as 
there are no corroborated compression fractures in those regions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22510, 22512, 22513, 22515).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #10, core buildup (D2950) 
for tooth #10, and a bone graft (D6104) for tooth #12 and #13. 
 
You asked the Plan to pre-approve the dental services. You say that the dental procedures are medically 
necessary because you can only chew with your front teeth. The Plan denied your request. The Plan says your 
benefit for the requested items or 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 Plan's 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 pre-approved a crown (D2740) for tooth #7, #8, and #9, core buildup (D2950) for tooth #7, #8, 
and #9, and a bone graft (D6104) for tooth #3 and #6 on November 8, 2023; therefore, your benefit for the 
requested items or services was exhausted on the date of approval of November 8, 2023. Therefore, we decided 
that the Plan does not have to pre-approve a crown (D2740) for tooth #10, core buildup (D2950) for tooth #10, 
and a bone graft (D6104) for tooth #12 and #13.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rystiggo. 
 
You asked the Plan to pre-approve Rystiggo. You say that the medication is medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the medication is not covered 
for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 
 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 Rystiggo. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Rystiggo is not Food and Drug 
Administration-approved for the treatment of myasthenia gravis that is anti-acetylcholine receptor and anti-
muscle-specific tyrosine kinase antibody negative. The use of Rystiggo for the treatment of seronegative 
myasthenia gravis is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The use of Rystiggo for the treatment of seronegative myasthenia gravis does 
not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rystiggo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rystiggo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical shoes (L3260). 
 
You asked the Plan to pre-approve surgical shoes. You say that the item is medically necessary. 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 surgical shoes (L3260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 9, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic 
image (D0230) provided on August 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 60 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 driving distance for a one-way trip is within 50 miles.  
 
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. Specifically, the provider is 
located 66 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 25, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 25, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided to the enrollee on 
January 9, 2023.

You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says that this testing is not covered. Maximus 
overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply 
the correct criteria, as this service was not covered at the time of service. The Plan is correct 
in this case. The rules say that that only the Progensa PCA3 and ConfirmMDx tests have met Medicare 
coverage criteria. We looked at the file and Medicare rules. The testing at issue is SelectMDx. 
This test was not covered by Medicare at the time the service was received.
Based on this information, we decided that Medicare rules for coverage of the SelectMDx testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx 
testing provided to the
enrollee on January 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter COVID-19 test (K1034) provided on 
June 26, 2023. 
 
You asked the Plan to pay for an over-the-counter COVID-19 test. You say that you want the Plan to pay for 
this. The Plan denied your request. The Plan says over-the-counter COVID-19 tests are not covered by 
Medicare after May 11, 2023.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and an over-the-
counter COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for an over-
the-counter COVID-19 test (K1034) provided on June 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the elective bariatric surgery provided from June 
12, 2023, to June 14, 2023, outside of the Plan's service area. 
 You asked the Plan to reimburse you for the out-of-area surgery. You say that you tried to get this approved to 
be done in the states for two years. You say that you were forced to go outside of the United States. You also 
say that you needed this to help with your weight and condition. The Plan denied your request. The Plan says 
the services in this case were not urgent or emergent in nature. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the out-of-area surgery have not been met. Specifically, the file indicates that the service at issue 
was elective and not urgent or emergent in nature. Therefore, we decided that the Plan does not have to 
reimburse you for the elective bariatric surgery provided from June 12, 2023, to June 14, 2023, outside of the 
Plan's service area.