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

 
We decided that the Plan does not have to pre-approve oral hygiene instructions (D1330) and an intraorifice 
barrier (D3911) for tooth number 12 and tooth number 21. 
 
You asked the Plan to pre-approve oral hygiene instructions (D1330) and an intraorifice barrier (D3911) for 
tooth number 12 and tooth number 21. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says oral hygiene instructions (D1330) and intraorifice barriers (D3911) are not 
on the list of covered services and therefore not a covered benefit. 
 
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 oral 
hygiene instructions (D1330) and an intraorifice barrier (D3911) for tooth number 12 and tooth number 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240), a 
retainer crown-porcelain fused to high noble metal (D6750), and a prefabricated post and core in addition to a 
crown (D2954). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 retainer crown and pontic was exhausted on date of service October 19, 
2022. Specifically, the Plans contract states that coverage is provided for one retainer crown and one pontic 
every 60 months. You previously received these dental items on October 19, 2022, less than 60 months prior, 
which were paid for by the Plan. Therefore you have exhausted the allowable benefit for these items requested 
in this case. Additionally, the Plans contract states that one prefabricated post and core in addition to a crown 
is covered once every 60 months. You previously received this dental item on February 27, 2023, less than 60 
months prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this 
dental item. Therefore, we decided that the Plan does not have to pre-approve a pontic-porcelain fused to high 
noble metal (D6240), a retainer crown-porcelain fused to high noble metal (D6750), and a prefabricated post 
and core in addition to a crown (D2954).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) 
concurrent with carotid stent placement.  
 
You asked the Plan to pre-approve the requested PTA procedure. You say that the facility is a CMS-certified 
carotid stenting facility, and the enrollee has great than 80% stenosis. The failure of the prior CEA supports 
that the enrollee is high-risk for another CEA. The Plan denied your request. The Plan says the enrollee is not 
participating in a clinical trial or registry as required.  
 
The Plan must follow Medicare rules. Medicare rules say that PTA concurrent with CAS may only be covered 
when the enrollee is participating in a CMS-approved study.  
 
We looked at the file and Medicare rules. While we have confirmed that this facility is a CMS-approved CAS 
facility, per a Maximus request, the provider confirmed with the Plan that the enrollee is not to be part of a 
clinical registry or trial, which is required for Medicare coverage per the NCD. The enrollee or provider may 
wish to confirm whether a study exists with which the enrollee may participate. Based on this information, we 
decided that Medicare rules for coverage of the requested PTA procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) concurrent 
with carotid stent placement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 09, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. 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 wound care supplies 
provided on September 09, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays of the pelvis and fingers provided on February 21, 
2023. 
 
You asked the Plan to pay for x-rays of the pelvis and fingers. You say that you do not understand why the 
doctor did not get prior authorization. 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 x-rays of the pelvis and 
fingers provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of a tooth with a 
rubber dam (D3910) and the canal preparation and fitting of a preformed dowel or post (D3950). 
 
You asked the Plan to pre-approve these dental 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 surgical procedure for isolation of a tooth 
with a rubber dam (D3910) and the canal preparation and fitting of a preformed dowel or post (D3950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items 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 items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on March 16, 2023. 
 
You asked the Plan to pay for wound care. You say that you are requesting the submitted documentation be 
reviewed. 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 wound care provided on 
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve chiropractic care . You say that you would like to continue seeing your 
doctor. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 03, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that this shouldve been billed 
to the VA. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on March 03, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Humira pen. 
 
You asked the Plan to pre-approve Humira. You say that Humira is a medical necessity for the enrollee. 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Humira pen.   
Benefits for Humira 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Simponi Aria (J1602). 
 
You asked the Plan to pre-approve Simponi Aria. You say that Simponi Aria is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says Simponi Aria has been prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Simponi Aria. Our reviewer says that 
treatment with Simponi Aria is not medically reasonable and necessary in this case. Our physician reviewer 
found that the requested use of Simponi Aria is not FDA-approved for the enrollee's diagnosis. Simponi Aria is 
approved for the treatment of rheumatoid arthritis in combination with methotrexate. The provided records do 
not document that the enrollee in this case is being treated (or will be treated) with methotrexate. The use of Simponi Aria without methotrexate for treatment of rheumatoid arthritis is not supported by one of the major 
drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Simponi Aria (J1602).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on April 16, 2022. 
 
You asked the Plan to pay for the ER visit. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says this facility is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the ER visit provided on April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Part B drugs, and vitamin injections provided on 
February 6, 2023. 
 
You asked the Plan to pay for the Part B drugs and vitamin injections. You say that this claim should be 
reprocessed and paid. The Plan denied your request. The Plan says the subcutaneous injection of the 
pharmaceutical substances is not as approved use of these medications. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted 
using a compounded drug, not otherwise classified (NOC) code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Part B drugs, and vitamin injections have not been met. The multiple drug codes reported on 
this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug 
be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, 
payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also 
cannot be paid. Therefore, we decided that the Plan does not have to pay for the Part B drugs, and vitamin 
injections provided on February 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were treated 
poorly. 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 $125 
copayment for ambulance services. 
 
You have been asked to pay a $125 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 December 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telomerase reverse transcriptase (TERT) gene analysis 
(81345-GZ) provided on February 1, 2023. 
 
You asked the Plan to pay for the TERT gene analysis. You say that you are requesting the denial be 
overturned and reprocessed The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that Medicare 
contractors that process both institutional and professional claims have discretion to automatically deny claim 
line(s) items billed with the GZ modifier. 
 
We find that CPT code 81345-GZ is not supported in the medical record. Specifically, this code is not 
supported as it was billed with a modifier that indicates it is not covered. Based on this information, we decided 
that Medicare rules for coverage of the TERT gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for the telomerase reverse transcriptase (TERT) gene analysis (81345-GZ) provided 
on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on February 9, 
2023, by an OON provider.  
 
You asked the Plan to pay for a compression device. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 a pneumatic compression device provided on 
February 9, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. 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 November 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the additional trips are 
needed because your physical capabilities are likely to decrease due to your condition. The Plan denied your 
request. The Plan says we confirmed via email with the Plan's designated provider's representative that you still 
have 4 one-way trips remaining. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when 6.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve four 
additional routine transportation trips. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
four additional routine transportation trips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step therapy rules for coverage of Euflexxa have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
treatment with Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).