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

 
We decided that the Plan does not have to pre-approve immediate maxillary denture (D5130), and to pre-
approve more for extraction of an erupted tooth (D7140). 
 
  You asked the Plan to pre-approve immediate maxillary denture (D5130), and to pre-approve more for 
extraction of an erupted tooth (D7140). You say that you are very sore and need this procedure quickly. You 
also say that you have $892 dollars left in my dental account that should be mine. The Plan denied your 
request. The Plan says immediate maxillary dentures (D5130) are not covered by the Plan benefit. The Plan 
also says that for the extraction of an erupted tooth (D7140), you are requesting to go to an out-of-network 
dentist. The Plan also says that the coinsurance level will apply to the average negotiated in-network fee 
schedule (INFS) in the member's area. The member is responsible for the difference between the INFS and 
dentists' charged fees when visiting an out-of-network dentist. 
 
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 immediate maxillary denture 
(D5130) are not among those covered under this benefit. The Plan rules also say that out-of-network dentists 
have not agreed to provide services at contracted fees. Benefits received out-of-network are subject to any in-
network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider 
for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan 
does not have to pre-approve immediate maxillary denture (D5130), and to pre-approve more for extraction of 
an erupted tooth (D7140).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional SNF days. 
 
You asked the Plan to pre-approve additional SNF days. You say that admission to the SNF will speed up the 
rehabilitation process. You also say that with the 2024 calendar you are eligible for more SNF days. The Plan 
denied your request. The Plan says you have used the 120 SNF days per benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 122 days of SNF care during the benefit period from January 28, 2023, to 
August 20, 2023. The Plan has covered 120 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 120 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional SNF days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-rays (D0230 x2), vertical bitewings 
(D0277), prophylaxis (D1110), and extraction (D7210) provided on July 24, 2023, by an out-of-network 
(OON) provider. 
 
  You asked the Plan to pay for the dental services. You say that you are asking for an exception to the Plan's 
policy, and you would like to be reimbursed for the services that were denied. You also say that the dental 
work provided was needed, urgent, and took care of the enrollee's facial pain which was being caused by an 
infected tooth. The Plan denied your request. The Plan says the dental services were received from an OON 
provider and are not covered by your supplemental benefits. The Plan says prior to the date of service, on April 
17, 2023, the enrollee called to inquire about a dental providers status, were told they only had coverage for 
in-network providers, and were emailed a list of in-network dentists and benefits. On May 5, 2023, the 
enrollee's representative contacted the Plan to verify deep cleaning and was told the benefits. The Plan also 
says that the benefits and a list of in-network periodontics were again sent to the enrollee. 
 
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 the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), 
additional intraoral periapical x-rays (D0230 x2), vertical bitewings (D0277), prophylaxis (D1110), and 
extraction (D7210) provided on July 24, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and each additional 
periapical x-rays (D0230) provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the benefit has 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 $1,000 towards services on May 12, 2023, and July 1 ,2023, which exhausted the benefit. 
Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and each 
additional periapical x-rays (D0230) provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on August 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service September 13, 2021.  
  
 
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images is 
covered every three plan years. You previously received this service on September 13, 2021, less than three 
years prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the service 
provided in this case. Therefore, we decided that the Plan does not have to pay for the intraoral-comprehensive 
series of radiographic images (D0210) provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased on September 
13, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you had no choice but to buy the machine so 
you would have one before you left to go overseas. You also say that you should be reimbursed for the cost of 
the portable oxygen machine that you purchased. The Plan denied your request. The Plan says the purchased 
oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
 
  In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. The record shows that there were multiple Medicare certified Durable Medical 
Equipment (DME) supplies within 25 miles of your home that you could have rented this equipment from. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased on 
September 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260) and gingival irrigation (D4921) 
provided on September 1, 2023, from an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you could not find an in-network provider. 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 osseous surgery (D4260) and gingival irrigation (D4921) provided on September 1, 2023, from an 
out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultralightweight wheelchair (K0005).  
You asked the Plan to pre-approve the wheelchair. You say that the enrollee cannot walk properly and the 
ultralightweight wheelchair is needed. The Plan denied your request. The Plan says under Medicare guidelines, 
your request is not medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
Medicare rules say that, in no case can the RUL of equipment be less than 5 years. The rules also say that 
replacement due to wear is not covered during the RUL of the equipment. 
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair including the already recently received 
lightweight wheelchair (K0003) to do your MRADLs in the home. In addition, there is no documentation you 
had a wheelchair chosen by a wheelchair specialist called an Assistive Technology Professional. The item 
being requested shows to be for replacement of an identical or nearly identical item, due to wear. The case file 
shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due 
to wear is not covered at this time. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the ultralightweight wheelchair (K0005).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that at the time of the appeal, IRF case was medically
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not 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 at the time of the appeal, the medical records show you were non-weight bearing
with your upper extremities. The medical records do not indicate you had the ability to participate in 3 hours of
therapy per day, 5 days per week.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
medical records provided do not show all of the required criteria for IRF care were met at the time of the
appeal. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility
(IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on June 24, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
information. 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 proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. 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 diabetic supplies 
provided on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical extractions for teeth #14 and #15 (D7210 x2) 
provided on August 4, 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 1, 2023. Therefore, 
we decided that the Plan does not have to pay for surgical extractions for teeth #14 and #15 (D7210 x2) 
provided on August 4, 2023. .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D6010, D6057, and D6065). 
 
You asked the Plan to pre-approve the dental services (D6010, D6057, and D6065). You say that you would 
like to request reconsideration of the denied dental services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services (D6010, D6057, and D6065).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415 and 80061 performed on May 15, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure codes 36415 and 80061 performed on May 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87798, 87653 and 87481) provided to the
enrollee on November 16, 2022.

You asked the Plan to pay for these lab services. The Plan denied your request. The Plan says the Medicare
billing criteria were not 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 this denial was for an incorrect billing process.
The Plan noted a test panel is a single test with multiple components and is characterized by a single unit of
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that
the test reports multiple individual pathogens and/or targets.

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, this claim could not be paid as billed due to the reporting of each code for
payment separately as opposed to being billed as one code for the test panel itself as Medicare requires.
Therefore, we decided that the Plan does not have to pay for lab services (87798, 87653 and 87481) provided to
the enrollee on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88377 billed for date of service September 6, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that this service was medically necessary. 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 88377 is 5. The MAI value for this code is 3. You billed 11 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 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on June 6, 2023. 
 
You asked the Plan to pay for procedure code 99232 provided on June 6, 2023. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 procedure code 99232 provided on 
June 6, 2023, have been met. In this case, there were no medical records provided for the June 6, 2023, date of 
service. Therefore, we decided that the Plan does not have to pay for procedure code 99232 provided on June 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on April 27, 2023. 
 
You asked the Plan to pay for the genicular nerve block. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered. 
 
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 pay for the genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-spinal electrical osteogenesis stimulator 
(E0747) 
 
You asked the Plan to pre-approve osteogenesis stimulator . You say that you are requesting reconsideration of 
the authorization for a bone growth stimulator. The Plan denied your request. The Plan says the Medicare 
criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case the records received did not show that the enrollee has a broken long bone that has not healed; that 
the enrollee has had x- rays at least 90 days apart that show the broken bone is not healing and that the enrollee 
has a failed fusion of a joint other than the spine and nine months have passed since surgery.  Therefore, we 
decided that the Plan does not have to pre-approve the non-spinal electrical osteogenesis stimulator (E0747)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care. 
 
You asked the Plan to pre-approve custodial care. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 custodial care 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 pre-approve custodial care.