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

 
We decided that the Plan does not have to pre-approve collection and application of an autologous blood 
concentrate product (D7921) and placement of an intra-socket biological dressing to aid in hemostasis or clot 
stabilization, per site (D7922). 
 
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 collection and application of an autologous 
blood concentrate product (D7921) and placement of an intra-socket biological dressing to aid in hemostasis or 
clot stabilization, per site (D7922).
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 the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services available at a LTACH that are not available at the current 
setting that is being offered by the Plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not requires services at a LTACH that are not available at the 
acute care hospital where they are currently receiving care.  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional OT visits are necessary for 
the enrollee.  The Plan denied your request. The Plan says the additional OT visits are not medically necessary 
per LCD L33631.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee resides at a skilled nursing or long-term care facility and 
require assistance with their daily activities. The enrollee has been receiving ongoing OT and their ability to 
perform daily activities has varied between requiring moderate assistance to require maximum assistance. The 
enrollee's level of function in terms of preforming dressing, bathing and toileting has not significantly changed 
and does not require the continued services of skilled OT. Therefore, the 10 additional OT visits are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy (OT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia  first 15 minutes 
(D9222), deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), guided tissue regeneration, natural teeth  resorbable barrier, per site (D4266), and bone 
replacement graft for ridge preservation - per site (D7953) provided in July 14, 2022. 
 You asked the Plan to pay for the dental services. You say that this is not a dental claim. The Plan denied your 
request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the deep sedation/general 
anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 minute increment 
(D9223), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), guided tissue regeneration, natural teeth  resorbable 
barrier, per site (D4266), and bone replacement graft for ridge preservation - per site (D7953) provided in July 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a dental crown for the enrollee.

You asked the Plan to provide coverage for a dental crown. You say that at the time of the appeal, these dental
services were medically necessary. The Plan denied your request. The Plan says the requested service was not
covered based on the dental records. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a dental crown.
The Maximus Physician Reviewer determined that the enrollee presented with symptoms of a crack on tooth
#30. The dental records show "There is a large restoration present, and the tooth has good bone support. The
standard of care is to place a crown restoration to prevent further fracture of the tooth and to restore normal
masticatory function." The Plan requested a reopen and noted that their supplemental criteria note a crown is
covered when the services are medically necessary as defined by their criteria. The criteria require that
permanent molar teeth (ex: tooth #30) must have pathologic destruction involving 4 or more surfaces and 2 or
more cusps. The Plan is correct in this case. The clinical documentation is limited to two poor quality dental
radiographs. The limited clinical documentation does not support that the enrollee's tooth #30 had pathologic
destruction to the tooth by caries or trauma involving 4 or more surfaces and at least two cusps.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, the dental records provided do not show the enrollee met the
criteria required for coverage were met. Therefore, we decided that the Plan does not have to provide coverage
for a dental crown for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve mandibular partial denture. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
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 Plan covers mandibular 
partial denture when the services are medically necessary and reasonable. 
 
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 mandibular partial denture. Our 
reviewer says that the service is medically necessary. Our physician reviewer found a removable partial denture 
is medically necessary for the enrollee as it will provide him more back teeth to chew his food and stop the 
drifting and shifting of his existing teeth that can potentially cause issues with his jaw. D5214 is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of mandibular partial denture have been met. Therefore, we decided that the Plan 
has to pre-approve mandibular partial denture (D5214).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network, and it was determined that the services can 
be provided by an in-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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
a continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9940). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested item is 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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard 
(D9940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for the intraoral complete 
series of radiographic images (D0210) provided on June 8, 2023. 
 
You asked the Plan to waive the deductible and coinsurance for the dental service. You say that you were told 
that the dental service would be covered but you now have a bill. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 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 50% 
coinsurance after a $100 deductible for class 2 basic services. The total allowed amount for the intraoral 
complete series of radiographic images (D0210) was $101.76 and the deductible charged was $100 leaving a 
remaining balance of $1.76 ($101.76 allowed - $100 deductible). The total coinsurance amount was $.88 
($1.76 balance x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance and a $100 deductible for the dental service. This item/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 deductible and coinsurance 
for the intraoral complete series of radiographic images (D0210) provided on June 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
15, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the PT visits are necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the additional PT visits. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had 23 PT visits and are currently performing a home 
exercise program and strengthening exercises. While you may continue to have some pain with walking, you 
are independent with mobility and performing daily activities. You can manage your pain with a home exercise 
program as the services of a skilled therapist are not needed to perform routine strengthening exercises. There 
is also a lack of documentation indicating you are making significant objective improvement with continued 
therapy in terms of strength, range of motion and function. Therefore, the 8 additional PT are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial dentures. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot speak properly and cannot eat 
well because of the missing tooth. You feel this is a necessary treatment.  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 14, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial dentures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service May 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing determines whether medications are 
beneficial and related to a cardiovascular diagnosis. The Plan denied your request. The Plan says the enrollee 
does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. 
 
The file shows that the enrollee received a combined cardio and pharmacogenomics testing panel. We looked at 
the file and Medicare rules. There are inconsistencies between the attestation and the medical records. The 
records do not document the need or intent for the testing to be performed. The records do not clearly 
document how the results of the testing will impact clinical management. It is not necessary to do genetic 
testing to provide or adjust medications. Based on this information, we decided that the Medicare coverage 
rules have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing billed 
for date of service May 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
17, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on February 25, 2023. 
 
You asked the Plan to pay for the vision services. You say that you did not have your identification card or 
your health card. You say the business would not apply your health card. The Plan denied your request. The 
Plan says an itemized and proof of payment were not submitted. 
 
Medicare generally does not cover supplemental vision services. However, the Plan offers a supplemental 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case 
 
Though the Plan offers a vision benefit in excess of Medicare coverage, the vision services are not covered. 
Specifically, the itemized bill was not submitted, which means the payment cannot be reimbursed. Therefore, 
we decided that the Plan does not have to pay for the vision services provided on February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), periodontal 
maintenance (D4910), porcelain or ceramic crown (D2740), core buildup (D2950), resin based composite for 
one anterior surface (D2330) and resin based composite for one posterior surface (D2391). 
 
You asked the Plan to pay for the dental services. You say that you were going to this office for several years 
and have had no problem, but this time the service was denied. The Plan denied your request. The Plan says the 
dental services 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 requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing (D4341), periodontal maintenance (D4910), porcelain or 
ceramic crown (D2740), core buildup (D2950), resin based composite for one anterior surface (D2330) and 
resin based composite for one posterior surface (D2391).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
(96365, 96366, and 96521) provided on June 6, 2023. 
 
You asked the Plan to pay for OIVIT services (96365, 96366, and 96521). You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services (96365, 96366, and 96521) provided 
on June 6, 2023.