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

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) kit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the criteria for coverage are 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. The Plan states that the criteria for coverage of the CGM are not met; however, 
no medical records were received with the case file. MAXIMUS requested this information but the Plan did not 
provide records. It is noted that you are a new member to this Plan; however, records are still required to 
support that the criteria are not met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM) kit.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you need the CGM to measure your glucose and to 
monitor if your sugar is high or low. 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. 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. Phone call logs not an acceptable substitution for medical records. Therefore, 
we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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 pay for an office visit provided on December 9, 2022, to December 
27, 2022, by an out-of-network (OON) provider.  
 
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 you did not receive a referral from your primary care 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 9, 2022, to 
December 27, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says it is unclear why this additional chest CT is being ordered. 
 
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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found that the pulmonary nodule of 6 millimeters 
should be followed up with at 6 months instead of 2 months. The current request is denied as it is too early for 
a repeated scan at this time. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on May 5, 2023. We also decided that the Plan does not 
have to pay for maxillary partial denture (D5213) provided on May 5, 2023. 
 
You asked the Plan to waive the coinsurance for the extraction. You also asked the Plan to pay for the 
maxillary partial denture. You say that you say that it is not fair that you received a bill. You also say that you 
cannot afford this and that is the purpose of the insurance. The Plan denied your request. The Plan says this 
cost sharing was charged correctly to the extraction. The Plan also says coverage is limited to the services listed 
in the Schedule of Benefits.  If a service is not listed, it is not included and is not covered. 
 
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 maxillary partial denture are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for maxillary 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5213) provided on May 5, 2023.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for Non-Medicare covered comprehensive dental services provided in-network which include 
extractions. 
 
You have been asked to pay a 50% coinsurance for the extraction. This service falls within the dental services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 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 waive the coinsurance for extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gammaglobulin (immunoglobulin) provided on June 6, 2023. 
 
You asked the Plan to pay for gammaglobulin (immunoglobulin). You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for gammaglobulin (immunoglobulin) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you went to the dentist and 
they found that your current partial damaged your tooth and they have to place a crown. You also say that you 
cannot use your old partial denture. The Plan denied your request. The Plan says your benefit for the requested 
mandibular partial denture 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 mandibular partial denture was last received D5214  partial lower denture on 
January 20, 2021. Therefore, we decided that the Plan does not have to pre-approve the mandibular partial 
denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you are high risk for type 2 diabetes.  The Plan denied 
your request. The Plan says the medical criteria for a CGM has not been. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would like this CGM. The Plan denied your 
request. The Plan says the medical criteria for a CGM has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
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).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015), frames (V2020), 
sphere, single vision lenses (V2100) and polycarbonate lenses (V2784) provided on December 5, 2022.  
 
You asked the Plan to pay for a determination of refractive state (92015), frames (V2020), sphere, single vision 
lenses (V2100) and polycarbonate lenses (V2784). You say that this was a routine eye examination. You also 
say that you ordered reading glasses that were included for free with the examination. The Plan denied your 
request. The Plan says the refractive services denied because that service is not covered. The Plan also says that 
the lens denied because the members plan benefit was 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 a $115 benefit toward the purchase and fitting of eyeglasses and pair of lenses 
or contact lenses (per calendar year). The Plan covers a determination of refractive state (92015) when it is a 
part of a routine eye examination.  
 
We looked at the file and the Plan's rules. The Plan rules say that they cover a $115 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (per calendar year). The record shows the benefit 
was exhausted with this date of service. The Plan rules also say that a refraction is only covered when billed as 
part of the routine eye examination. The record shows that this was a medical eye examination. Based on this 
information, we decided that the Plan's rules for coverage of a determination of refractive state (92015), frames 
(V2020), sphere, single vision lenses (V2100) and polycarbonate lenses (V2784) have not been met. Therefore, 
we decided that the Plan does not have to pay for a determination of refractive state (92015), frames (V2020), 
sphere, single vision lenses (V2100) and polycarbonate lenses (V2784) provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based indirect crowns (D2710). 
 
You asked the Plan to pre-approve D2710. You say that you need this dental work. The Plan denied your 
request. The Plan says the denied dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
resin-based indirect crowns (D2710).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot walk five or six 
steps without getting out of breath. The Plan denied your request. The Plan says a portable oxygen concentrator 
outside the home is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia- 
first 15 minutes (D9239), and intravenous moderate sedation/analgesia - each subsequent 15 minute increment 
(D9243). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these 
services are not covered. 
 
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 intravenous 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous moderate 
sedation/analgesia - each subsequent 15 minute increment (D9243).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 provided on January 17, 2023. 
 
You asked the Plan to pay for procedure code 87506. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87506 is Infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the records show that more 
than 11 pathogens were tested. There is a more appropriate code to bill for the services provided. Based on this information, we decided that Medicare rules for coverage of procedure code 87506 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87506 provided on January 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator purchased on April 5, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you have shortness of breath and need 
oxygen that can be taken with you to the store and to the doctor's office. The Plan denied your request. The 
Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator purchased on April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant /abutment supported removable denture for 
edentulous arch  mandibular (D6111), and unspecified removable prosthodontic procedure, by report (D5899) 
provided on March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you already have the implants so they had to 
make your denture to fit on the existing pegs. You also say that since your plan covers dentures you feel that 
this should have been approved having the Plan pay 75% and you with the remaining 25%. The Plan denied 
your request. The Plan says these services are not covered. 
 
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 pay for the implant 
/abutment supported removable denture for edentulous arch  mandibular (D6111), and unspecified removable 
prosthodontic procedure, by report (D5899) provided on March 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you drove 
to the fire station and there was no ambulance involved. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 4, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7140 x 2) provided on May 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan informed you that you would not 
have to pay anything if the services were under $1,500 and the provider told you the procedures were 
authorized. 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.  
 
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 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. 
Therefore, we decided that the Plan does not have to pay more for the extractions (D7140 x 2) provided on 
May 23, 2023.