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

 
We decided that the Plan does not have to pay for the dental service (D0381) on July 26, 2023. 
 
You asked the Plan to pay for the dental service (D0381). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D0381) on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraoral complete series of radiographic images 
(D0210). 
 
You asked the Plan to pre-approve the dental service. You say that your dentist deemed the prior x-rays 
unusable, and the x-rays are needed so your cavities do not go untreated. 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 the Plan paid for the intraoral complete series of radiographic images (D0210) on March 6, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of March 6, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the intraoral complete series of radiographic 
images (D0210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on August 1, 
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 physician order or relevant and current medical records which support 
medical necessity for the supplies provided in this case. The records provided are over a year 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) provided on August 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0230) on September 6, 2023. 
 
You asked the Plan to pay for the dental service (D0230). You say that you would like to request 
reconsideration for payment. 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 September 6, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental service (D0230) on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (provided on September 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 January 17, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings (provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical image (D0230), a pulp vitality test 
(D0460), and a diagnostic service consultation (D9310), provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not feel like you should owe anything. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 D0230 was exhausted on date of service September 11, 2023. Therefore, we decided that 
the Plan does not have to pay for an additional periapical image (D0230), a pulp vitality test (D0460), and a 
diagnostic service consultation (D9310), provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported to denture (D6112). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service 
because you have problems with your teeth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the abutment supported to denture is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
abutment supported to denture (D6112).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry care to remove calluses. 
 
You asked the Plan to pre-approve podiatry care to remove calluses. You say that you have calluses on each 
foot and if you dont get them treated it makes it very difficult to walk. You say that one time you tried to do it 
yourself and ended up cutting too deep and got a bad infection and your doctor told you to never do it again. 
The Plan denied your request. The Plan says that the clinical documentation indicates that you do not have a 
history of a systemic disease that would affect blood flow or feeling of your feet. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage 
of podiatry care to remove calluses have not been met. Therefore, we decided that the Plan does not have to 
pre-approve podiatry care to remove calluses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210) provided on August 17, 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 January 30, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic 
images (D0210) provided on August 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 13, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post removal (D2955). 
 
You asked the Plan to pre-approve the post removal. You say that tooth #30 retreatment is planned and the post 
must be removed in order to access the canals. The Plan denied your request. The Plan says dental code D2955 
is not listed as covered dental services. 
 
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 the 
post removal (D2955).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the mandibular denture. You say that you are scheduled for teeth extractions 
and afterwards your current partial will no longer fit. You also say that you are in need of new complete set of 
dentures. The Plan denied your request. The Plan says this service is not covered in your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that you need this to be denied so this 
can be submitted to the enrollee's secondary insurance for approval. The Plan denied your request. The Plan 
says the notes do not show that the enrollee has a condition which would necessitate a Group 3 power 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options (K0861).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of 
medical decision making (99285) provided on May 12, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was billed correctly. The 
Plan denied your request. The Plan says the documentation does not support the services as 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 99285 is an emergency department visit for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the emergency department visit. Our reviewer says that the documentation does not support the services. Our reviewer found the medical records provided does not 
include sufficient documentation to validate that a level 99285 - Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making was performed on May 12, 2023, therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making (99285) provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified maxillofacial prosthesis by report (D5999) 
provided on February 24, 2023. 
 
You asked the Plan to pay for unspecified maxillofacial prosthesis by report. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
unspecified maxillofacial prosthesis by report (D5999) provided on February 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the Intracept procedure 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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found that the Intracept 
procedure is considered experimental. Also, there is no magnetic resonance imaging (MRI) showing only 
modic changes without facet degenerative joint disease or stenosis, and the cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this exam, so you had clearance for 
a shoulder surgery. 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 February 8, 2023, and August 9, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 26, 
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 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 June 16, 2023, and 
September 14, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on September 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide or certified nurse assistant providing 
care in the home provided from June 15, 2023, to August 31, 2023. 
 
You asked the Plan to pay for the home health aide services. You say that you do not understand why the Plan 
will not pay for the home health services. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the services rendered are custodial in nature. 
 
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 the home health aide services 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 pay for the 
home health aide or certified nurse assistant providing care in the home provided from June 15, 2023, to 
August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided out of the United States on 
September 9, 2023. 
 
You asked the Plan to pay for dental services provided out of the United States. You say that this was 
medically necessary. The Plan denied your request. The Plan says services provided outside of the United 
States 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, only dental services provided by a 
licensed provider in the United States is covered under this benefit. 
 Therefore, we decided that the Plan does not have to pay for dental services provided out of the United States 
on September 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies billed to the enrollee for date of service
November 25, 2022.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says a place of service code 12,
for the home, cannot be reported with type of bill code 111, which indicates an inpatient status. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not review the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Place of Service code indicating the delivery was to the home cannot
then be billed with a type of bill code of 111, as this indicates inpatient service. Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for wound care supplies
billed to the enrollee for date of service November 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 5, 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 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 January 24, 2023, and 
May 2, 2023. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
September 5, 2023.