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

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on July 28, 
2023. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you did not know that the 
provider was no longer in-network. 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 $65 
copayment for each out-of-network Medicare-covered vision exam. 
 
You have been asked to pay a $65 copayment for a medical eye exam. This item/service falls within the each 
out-of-network Medicare-covered vision exam 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 medical eye exam provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided July 13, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. 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 a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided 
July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided March 2, 
2023, to April 3, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee received post-
operative treatment from March 2, 2023, through April 3, 2023. The Plan denied your request. The Plan says a 
PCD coded as E0675 is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided March 2, 2023, to April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BluePrint test (81599) provided on June 1, 2023. 
 
You asked the Plan to pay for the BluePrint test. You say that the results of this test are expected to play a 
significant role in finding the appropriate therapy for the enrollee. The Plan denied your request. The Plan says 
this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the BluePrint test is a statutorily excluded test. 
 
We looked at the file and Medicare rules. The requested test is excluded from coverage.  Therefore, we decided 
that the Plan does not have to pay for the BluePrint test (81599) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953 ). 
 
You asked the Plan to pre-approve bone replacement graft. 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 pre-approve bone 
replacement graft (D7953 ).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 17, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that 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 psychotherapy provided 
on August 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dalfampridine. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is the only medication to 
treat ambulation in patients with Multiple Sclerosis (MS). The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve dalfampridine.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic dental crowns (D2740 x 2) and 
endodontic therapy, of a premolar tooth (excluding final restoration) (D3320). 
 
You asked the Plan to pre-approve the dental items/services. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says dental items/services rendered by an out-of-
network provider are not covered by 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. 
 
  
 
You are not a network provider with the Plan. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested items/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 pre-approve porcelain/ceramic dental crowns 
(D2740 x 2) and endodontic therapy, of a premolar tooth (excluding final restoration) (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245). 
 
You asked the Plan to pre-approve a pontic. 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 pre-approve a 
pontic (D6245).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug screening provided to the enrollee on October 20,
2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the drug screening. You say that you are requesting reconsideration of the denied
claim. The Plan denied your request. The Plan says that this service was not authorized with an out-of-network
provider. Maximus overturned the Plan's denial for a lack of information. The Plan requested a reopening and
provided the 2022 Evidence of Coverage.

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 the drug screening provided to the enrollee on
October 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronary therapuetic services described by codes 92925 
and 92929 performed on May 22, 2023, and the discharge day management services described by code 99239 
performed on May 23, 2023. 
 
You asked the Plan to pay for 92925, 92929, and 99239. You say that 92925, 92929, and 99239 should be paid 
as billed because they are supported in the medical record. The Plan denied your request. The Plan says 92925 
and 92929 are denied because they are considered bundled and not separately payable. 99239 is denied because 
it is not supported in the medical record. 
 
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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that procedure codes 92925 and 92929 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 92925 and 92929 are not separately payable. We also find that CPT code 
99239 is not supported in the medical record. Specifically, the code definition is time-based, and the records 
submitted for review do not document the total time spent providing the services described by this code. Based 
on this information, we decided that Medicare rules for coverage of 92925, 92929, and 99239 have not been 
met. Therefore, we decided that the Plan does not have to pay for the coronary therapuetic services described 
by codes 92925 and 92929 performed on May 22, 2023, and the discharge day management services described 
by code 99239 performed on May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot orthotics (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that you have calluses and a bone that has to be 
removed by surgery. You also say that you need the foot inserts to be able to walk. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6060), prefabricated abutment (D6056), and surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve these dental services. 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 pre-approve 
abutment supported porcelain fused to metal crown (D6060), prefabricated abutment (D6056), and surgical placement of implant body (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair (E0240) and a raised toilet seat 
(E0244). 
 
You asked the Plan to pre-approve a bath/shower chair and raised toilet seat. You say that you have severe 
rheumatism and back pain. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair (E0240) and a 
raised toilet seat (E0244).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4261). 
 
You asked the Plan to pre-approve osseous surgery. 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 pre-approve 
osseous surgery (D4261).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service June 28, 
2023.  
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87634 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87634 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87634 billed for date of service June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Jazzy Air 2 power wheelchair (K0899). 
 
You asked the Plan to pre-approve a Pride Jazzy Air 2 power wheelchair. You say that you cannot use a 
manual wheelchair because of your shoulder and elbow injuries, two torn rotator cuffs and arthritis and bursitis 
in your elbows, so your arms are not useful and easily aggravated. The Plan denied your request. The Plan says 
the requested power wheelchair has not been reviewed by the PDAC contractor or has been reviewed and 
found to not meet the definition of a specific power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that POVs and PWCs which have not been reviewed by the 
PDAC will be denied as not reasonable and necessary and should be coded as K0899. 
 
 
 
 
 
 We find that the type of scooter you requested has not been reviewed by the PDAC and carries the Healthcare 
Common Procedure Coding System (HCPCS) code of K0899. This means that the scooter in dispute is not 
considered reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a Pride 
Jazzy Air 2 power wheelchair (K0899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft-of a retained natural tooth-first 
site in quadrant (D4263), the extraction, of an erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210), and the surgical placement of an implant body: endosteal implants (D6010 x 2).  
 
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 a bone replacement graft-of a retained natural 
tooth-first site in quadrant (D4263), the extraction, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), and the surgical placement of an implant body: endosteal implants (D6010 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver and sensors. 
 
You asked the Plan to pre-approve the Dexcom G7 receiver and sensors. You say that you have been having 
platelet treatments due to your blood sugar dropping. You also say that they believe the medication would help 
you with your blood sugar and assist you by not having to continue to get platelet treatments.  The Plan denied 
your request. The Plan says you are not receiving insulin and have not had documented hypoglycemic 
episodes, so the CGM is not medically necessary and not covered by Medicare. 
 
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 you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the Dexcom G7 receiver and sensors. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 receiver and sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for the total electric hospital bed provided on 
July 27, 2023. 
 
You asked the Plan to reimburse the enrollee for the total electric hospital bed. You say that the evidence of 
benefits (EOB) for the date of service in this case indicates that the provider previously received payment. You 
say that the enrollee paid $265 out-of-pocket. You also say that the enrollee has not received reimbursement. 
The Plan denied your request. The Plan says total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to reimburse the enrollee for the total 
electric hospital bed provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor for the enrollee.

You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the enrollee has severe diabetic
neuropathy which limits mobility and feeding, lacks dexterity to safely use traditional glucometer and test
strips. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria. Maximus
overturned the Plan's denial. The Plan requested a reopening and states that the enrollee does not use insulin or
have a history of problematic hypoglycemia. The Plan is correct in this case. The documentation indicates that
the enrollee does not use insulin or have a history of problematic hypoglycemia. There is no documentation of
a hypoglycemic episode with a blood sugar less than 54. Based on this information, we decided that Medicare
rules for coverage of a Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Freestyle Libre 2 sensor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 01, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. 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 the medical services 
provided on September 01, 2023.