Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an arthrocentesis (procedure code 20611) performed on February 17, 
2023. 
 
You asked the Plan to pay for an arthrocentesis (procedure code 20611). You say that you are requesting the 
claim be reviewed and reprocessed for payment. The Plan denied your request. The Plan says that the services 
performed are considered experimental or investigational and are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for an arthrocentesis (procedure code 20611). 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the injection was conducted with an FDA approved medication in the 
prescribed manner. The injection was medically reasonable and 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 an arthrocentesis (procedure code 20611) have been met. Therefore, we decided 
that the Plan has to pay for an arthrocentesis (procedure code 20611) performed on February 17, 2023.  
 
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 pay for the pneumatic compression device provided on May 30, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network durable medical 
equipment (DME) provided on April 30, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network durable medical equipment (DME). You say 
that you disagree with the coinsurance. 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 for out-of-network durable medical equipment (DME). 
 
You have been asked to pay 50% coinsurance for out-of-network durable medical equipment (DME). This 
item/service falls within the out-of-network durable medical equipment (DME) 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 out-of-network durable medical equipment (DME) provided on 
April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
27, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 a $30 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 copayment 
for a specialist office visit provided on June 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
March 27, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be 
held responsible for the copayment. 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 a $270 
copayment for ambulance services. 
 
You have been asked to pay a $270 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 copayment for the 
ambulance transportation provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
August 02, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not call for 
the ambulance and you should not be held responsible for the copayment. 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 a $240 
copayment for ambulance services. 
 
You have been asked to pay a $240 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 copayment for the 
ambulance transportation provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on April 27, 2023. 
 
You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a mental health visit 
provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg with an advanced foot and
electronic knee feature for the enrollee.

You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal this
equipment was medically necessary. The Plan denied your request. The Plan says the records provided do not
support this request. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria. The provider's notes do not show why a mechanical knee cannot be
used for the enrollee's prosthesis, especially given the weight a microprocessor knee and the enrollee's comorbidities.
The medical records do not give any medical reason why a mechanical K3 knee will not meet the
enrollee's need. The Plan also states a microprocessor knee weighs more than a mechanical knee. A
microprocessor knee is more prone to damage and corrosion, especially when exposed to water. A
microprocessor knee requires more maintenance, such as maintenance of charge for the battery, and avoidance
of water.

This is the enrollee's initial knee, and the enrollee has not trialed a mechanical K3 knee. Therefore, the
requested microprocessor knee exceeds the enrollee's need and is not reasonable and necessary per Medicare
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we
decided that there is insufficient information in the record to determine if Medicare rules for coverage of this
equipment have been met. Therefore, we decided that the Plan does not have to provide coverage for a
prosthetic leg with an advanced foot and electronic knee feature for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6245 x1, D6212 x1) and a retainer crown (D6740) 
provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you made sure the services were all going to be 
covered and then you received a letter telling you they were not all covered. 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 your benefit for the requested items or services was exhausted on date of service May 30, 2023. 
Therefore, we decided that the Plan does not have to pay for pontics (D6245 x1, D6212 x1) for tooth #12 and 
#14 and a retainer crown (D6740) for tooth #11 provided on May 30, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 80307 and G0482 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for the services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that the provided 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  80307 is: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; 
by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, 
RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, 
DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation 
when performed, per date of service. The CPT code manual definition of code G0482 is: Drug test(s), 
definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between 
structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or 
tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and 
enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal 
standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and 
(3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for 
instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen 
validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
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 services. Our reviewer found the documentation 
submitted includes orders and results for the presumptive and definitive drug tests. Therefore, the record 
supports that these tests were performed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 80307 and G0482 billed for date of service July 28, 2022.  
 
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 nurse practitioner services provided on May 23, 2023. 
 
You asked the Plan to pay for nurse practitioner services. You say that the patient was homebound and not able 
to go to an in-network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nurse practitioner 
services provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided by a denturist on May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee's handbook says that the dentures 
are covered at 100% and it is not specified that it must be completed by a general dentist. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the dentures were completed 
by a denturist, and they are 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 items or services are only 
covered under the Plans dental benefit when they are performed by a dentist. Therefore, we decided that the 
Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) 
provided by a denturist on May 1, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes H0006 and H0015. 
 
You asked the Plan to pre-approve procedure codes H0006 and H0015. You say that the services were billed 
correctly. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes H0006 and H0015 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes H0006 and H0015 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of H0006 and H0015 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve procedure codes H0006 and H0015.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 09, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance 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 copayment for ambulance services 
provided on April 09, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor.

You asked the Plan to pre-approve these services. You say that you were denied the Dexcom G7 because you
had already received the G6. The Plan denied your request. The Plan says that coverage for CGM receivers is
limited to one every three years.

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 previous determination stated that the Plan did not make reasonable and diligent efforts to forward proof
that the enrollee received a CGM receiver on September 29, 2022. After reviewing the documentation, the Plan
still has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that The Plan states that the Dexcom G7 CGM received cannot be
covered because you received a CGM receiver on September 29, 2022, and this item can only be covered once
every three years. The Plan cites the Centers for Medicare & Medicaid Services (CMS) Ruling 1738-R;
however, this ruling does not state that a CGM receiver is only covered once every three years. The ruling
states that the definition of durable medical equipment (DME) is an item that has an expected life of three
years, but there is no text explicitly stating that the CGM receiver is only covered once every three years. The
Plan has not provided any binding Medicare rules to support that the Dexcom G7 sensor cannot be approved.
Therefore, we decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor (CGM)
sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns
(D6740) for tooth #3 and #5.

You asked the Plan to pre-approve these dental services. The Plan denied your request. The Plan says the
records provided do not show the dental benefit coverage criteria are met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted
that the Plan must receive documentation that indicates or supports a specific physical or psychological
condition(s) that precludes the use of a removable prosthesis. The Plan received additional information during
the appeal process. The records do not include a specific physical or psychological condition that precludes the
use of a removable prosthesis. Therefore, the Plan determined the denial was correct.

The Plan is correct in this case. 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.
The Plan covers these dental services when the dental records show specific reasons as to why a removable
prosthesis cannot be used by the enrollee. Based on the lack of this information being present in the dental
records provided, the Plan's rules for coverage of these dental services have not been met. Therefore, we
decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740)
for tooth #3 and #5.