Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87801, 87798, 87481) provided to
the enrollee on February 13, 2023.

You asked the Plan to pay for the laboratory services. You say that these services were medically necessary and
are supported in the medical record. The Plan denied your request. The Plan says that it is the responsibility of
the out-of-network provider to provide supporting information and to code services correctly. Maximus
overturned the Plan's denial. The Plan requested a reopening and stated that these services were not supported
in the record. The Plan is correct in this case. 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 the
laboratory services have been met. Specifically, you have not provided any medical records from the
prescribing physician as to why these services were required. The only records provided are the test results and
nothing earlier. Therefore, we decided that the Plan does not have to pay for the laboratory services (87801,
87798, 87481) provided to the enrollee on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided from June 27, 2023, to 
July 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you went out-of-network to get the earliest 
appointment because it was an emergency. The enrollee cannot afford to pay, and you assumed you were 
covered in and out-of-network the same. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental services provided from June 27, 
2023, to July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that this is medically necessary. The 
Plan denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no history, 
physical examination, or concordant radiological image-based diagnostic testing supporting lumbar 
radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis, or post-
laminectomy syndrome. The review has determined that the enrollee does not meet the LCD criteria for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) for tooth #24 provided on 
August 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was recommended to save your teeth and to 
repair the cavity with a filling. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the resin-based composite is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2332) for tooth #24 provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown for tooth 27 (D6750). 
 
You asked the Plan to pre-approve retainer crown for tooth 27. 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 retainer 
crown for tooth 27 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 retainer crown for tooth 27. Our 
reviewer says that the service is medically necessary. Our physician reviewer found tooth #27 is an optimal 
tooth for bridges in the lower front teeth area due to the size and length of its root. Including tooth #27 as part 
of the bridge is not considered a splinting procedure. The force that the bridge will take due to eating and 
chewing food can cause an anchor tooth to become loose if the force is too great, this is why it is beneficial to 
include a third anchor for the bridge tooth #27. In this case D6750 for tooth #27 is medically reasonable and 
necessary to help support the bridge to replace three missing teeth. 
 
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 retainer crown for tooth 27 have been met. Therefore, we decided that the Plan 
has to pre-approve retainer crown for tooth 27 (D6750).  
 
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: 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 the enrollee requires and would benefit from the 
intense physical and occupational therapy provided in an IRF. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for an IRF admission.  
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to provide coverage for lower extremity angiography with potential interventions
for the enrollee.

You asked the Plan to provide coverage for this service. You say that this service is medically necessary for the
enrollee. The Plan denied your request. The Plan says that medical necessity had not been established.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that the original letter from
Maximus was inconsistent.

The Plan must follow Medicare rules. Medicare covers services that are found to be 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 pre-approve lower extremity angiography with
potential interventions. Our reviewer says that the requested services are considered medically reasonable and
necessary in this case. Our physician reviewer found the documentation supports lower extremity angiography
and possible intervention. The medical records show the enrollee has a diagnosis of resting ischemic pain of the
left lower extremity with a documented ABI 0.39. This may represent critical limb ischemia with limb threat.
Angiography to determine possible intervention are warranted. The enrollee also has a history of a right lower
extremity bypass.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of lower extremity angiography with potential interventions have been met.
Therefore, we decided that the Plan has to provide coverage for this service, lower extremity angiography with
potential interventions for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and each 
additional periapical x-ray (D0230 x 2) provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed to see a new provider and the 
procedures had to be redone. 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 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 items or services was exhausted on dates of service November 18, 2022, 
and June 13, 2023. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and each additional periapical x-ray (D0230 x 2) provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that your physician recommended this exam. The 
Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The test at issue in this appeal is being requested solely for screening 
purposes. The records do not show that you have signs or symptoms of breast cancer. Medicare does not cover 
the requested testing solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eyewear purchased on March 8, 2023.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $100 once per calendar year toward the purchase and fitting of eyeglasses and
a pair of lenses or contact lenses and you are responsible for any amount over the $100 benefit.

We looked at the file and the Plan's rules. The previous determination stated that the Plan had to pay $40 more
for these services because they paid only $60 on the claim; however, the file clearly shows that the Plan applied
more than the full $100 benefit towards your routine eyewear purchase. The Plan paid $60 and applied a
provider discount of $71.40, for a total of $131.40 in coverage. The remaining balance of $125.60 is your
responsibility. Further payment is not covered by your supplemental benefit or Medicare benefit. Therefore, we
decided that the Plan does not have to pay for the routine eyewear purchased on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you broke your denture and need a 
replacement. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 21, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for FreeStyle Kit sensors for the enrollee.

You asked the Plan to provide coverage for FreeStyle Kit sensors. 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 is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit
with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

Based on the medical records provided, all of the required criteria as listed are not met. Therefore, we decided
that the Plan does not have to provide coverage for FreeStyle Kit sensors for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the documentation submitted does not show that the 
enrollee has lymphedema extending onto the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the documentation submitted does not show that the 
enrollee has lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair push handles (K0108). 
 
You asked the Plan to pre-approve the wheelchair push handles. You say that the item should be covered. The 
Plan denied your request. The Plan says this item is for convenience and does not primarily serve a medical 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair push handles (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and the bitewings 
(D0274) provided by an out-of-network provider on June 27, 2023. 
  You asked the Plan to pay more for the dental services. You say that you have been with the dentist for years 
and this is the first time paying out-of-network. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
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 total amount billed for the periodic oral evaluation (D0120) was $67 and the total allowed amount was $23 
leaving a difference of $44 ($67 billed - $23 allowed). The total amount billed for the bitewings (D0274) was 
$77 and the total allowed amount was $27 leaving a difference of $50 ($77 billed - $27 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120) and the 
bitewings (D0274) provided by an out-of-network provider on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eyewear purchased on February 20, 2023.

You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your
request. The Plan says the claim was processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $100 once per calendar year toward the purchase and fitting of eyeglasses and
a pair of lenses or contact lenses and you are responsible for any amount over the $100 benefit.

We looked at the file and the Plan's rules. The previous determination stated that the Plan had to pay $45 more
for these services because they paid only $55 on the claim; however, the file clearly shows that the Plan applied
more than the full $100 benefit towards your routine eyewear purchase. The Plan paid $55 and applied a
provider discount of $82, for a total of $137 in coverage. The remaining balance of $148 is your responsibility.
Further payment is not covered by your supplemental benefit or Medicare benefit. Therefore, we decided that
the Plan does not have to pay for the routine eyewear purchased on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete maxillary denture (D5750) provided on 
March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pay for reline complete maxillary denture (D5750) provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $3,000 annual maximum 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 $3,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertical shock reducing pylon (L5988) for the
enrollee.

You asked the Plan to pre-approve a vertical shock reducing pylon. You say that the item is medically
necessary. The Plan denied your request. The Plan says that the item is not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a vertical shock
reducing pylon. Our Medical Director states that the available clinical documentation does not support that a
vertical shock reducing pylon is/was medically reasonable and necessary for this enrollee. Our Medical
Director found that the enrollee's condition does not meet criteria for coverage of a vertical shock reducing
pylon.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a vertical shock reducing pylon have not been met. Therefore, we decided that
the Plan does not have to pre-approve a vertical shock reducing pylon (L5988) for the enrollee.