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

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and the 
intraoral complete series of radiographic images (D0210) provided by an out-of-network provider on June 7, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the Plan's decision on 
denying your access to a second opinion from a provider outside of the Plan's network. 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 a comprehensive periodontal evaluation (D0180) and the intraoral complete series of radiographic 
images (D0210) provided by an out-of-network provider on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98940, 98941), office visit (99203), therapeutic exercises (97110), and the low level laser treatments (S8948) 
rendered by the out-of-network (OON) provider from September 22, 2023, through October 4, 2023.  
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 
rendered by an out-of-network provider without prior authorization.  
 
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 issue reimbursement for  care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
  
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98940, 98941), office visit (99203), therapeutic exercises (97110), and the low level laser treatments (S8948) 
rendered by the out-of-network (OON) provider from September 22, 2023, through October 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D5120 and D5110) on August 26, 2021. 
 
You asked the Plan to pay for the dental services (D5120 and D5110). You say that you would like to request 
reconsideration for payment. 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 the dental services (D5120 and D5110) on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), an intraoral 
complete series of radiographic images (D0210), a cleaning (D1110), and a resin-based composite (D2391) 
provided by an out-of-network provider on July 25, 2023, and August 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were informed that dental services 
would be covered going out-of-network and you would like the Plan to cover the proper amount. 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. The proper cost share was applied. 
Also, it was verified that the proper benefits and provider eligibility was given prior to the date of services. 
 
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 billed amount for the periodic oral evaluation (D0120) was $104 and the total allowed amount was 
$24 leaving a difference of $80 ($104 billed - $24 allowed). The total billed amount for the intraoral complete 
series of radiographic images (D0210) was $223 and the total allowed amount was $64 leaving a difference of 
$159 ($223 billed - $64 allowed). The total amount billed for the cleaning (D1110) was $174 and the total 
allowed amount was $64 leaving a difference of $110 ($174 billed - $64 allowed). The total amount billed for 
the resin-based composite (D2391) was $285 and the total allowed amount was $82 leaving a difference of 
$203 ($285 billed - $82 allowed). The total coinsurance amount was $41 ($82 allowed x 50% coinsurance). 
The total enrollee liability was $593 ($80 difference + $159 difference + $110 difference + $203 difference + 
$41 coinsurance). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment and a 50% coinsurance for the resin-based composite. 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), an intraoral complete series of radiographic images (D0210), a cleaning 
(D1110), and a resin-based composite (D2391) provided by an out-of-network provider on July 25, 2023, and 
August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0120 and D1110) on May 5, 2022. 
 
You asked the Plan to pay for the dental services (D0120 and D1110). You say that you would like to request 
reconsideration for payment. 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 May 5, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services (D0120 and D1110) on May 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on May 14, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on May 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
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. Specifically, the request for more information signed by the 
enrollees prescriber indicates that the enrollee does not use insulin or have a history of problematic 
hypoglycemia. Based on this information, we decided that Medicare rules for coverage of the CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is necessary due to the 
failure of conservative treatments to address pain.  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 pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma (0232T). 
 
You asked the Plan to pre-approve a platelet rich plasma. You say that the enrollee is unable to do the 
procedure on the dates that were previously approved. The Plan denied your request. The Plan says a platelet 
rich plasma is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. The records shows the injection was requested to treat pain in the 
enrollees left knee. Based on this information, we decided that Medicare rules for coverage of a platelet rich 
plasma have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich 
plasma (0232T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 26, 
2023, to August 27, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the treating physician determined that 
hospital care was appropriately provided as inpatient. The Plan denied your request. The Plan says this hospital 
stay was appropriate for observation level of care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of inpatient admission it was reasonable for 
the admitting physician to expect that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights with supporting documentation of the patients 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. The 
enrollee was evaluated in the emergency department on August 26, 2023. The enrollees vital signs were stable 
with no respiratory issues. The enrollee was treated for tongue swelling. The enrollee was admitted and 
monitored, then discharged with outpatient follow-up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 26, 2023, to August 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023 to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023 to September 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0140) provided on September 
18, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dentist appointment was an emergency and 
you had to have the evaluation done. 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 the Plan paid for a periodic oral evaluation (D0120) on May 15, 2023, and paid for a limited oral 
evaluation (D0140) on June 1, 2023; therefore, your benefit for the requested item or service was exhausted on 
the date of service of June 1, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation (D0140) provided on September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G device (L8702).

You asked the Plan to pre-approve a MyoPro Motion G device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 pre-approve a MyoPro Motion G device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current clinical guidelines for adult stroke rehabilitation and recovery designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. Although records from the device
manufacturer/vendor argue medical necessity of the requested device, records from the enrollee's actual treating provider do not clarify why the requested device is the most appropriate treatment for the enrollee's condition.

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 MyoPro Motion G device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement grafts (D7953) provided on June 26, 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 26, 2023. Therefore, 
we decided that the Plan does not have to pay for bone replacement grafts (D7953) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amalgams and fillings (D2160, D2161, D2331) provided on 
August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 August 17, 2023. 
Therefore, we decided that the Plan does not have to pay for amalgams and fillings (D2160, D2161, D2331) 
provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial dentures and mandibular partial dentures 
(D5213, D5214) provided on August 24, 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 September 13, 2021. 
Therefore, we decided that the Plan does not have to pay for maxillary partial dentures and mandibular partial 
dentures (D5213, D5214) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous, osteoperiosteal, or cartilage graft (D7950) 
for tooth #11. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
osseous, osteoperiosteal, or cartilage graft are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
osseous, osteoperiosteal, or cartilage graft (D7950) for tooth #11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Cogenex amniotic membrane (Q4229) for the
enrollee.

You asked the Plan to provide coverage for Cogenex amniotic membrane (Q4229). You say that this treatment
is medically necessary for the enrollee. The Plan denied your request. The Plan says medical necessity has not
been established. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not review the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Cogenex amniotic
membrane (Q4229). The Maximus Physician Reviewer determined that the requested item was medically
reasonable and necessary in this case. The reviewer found that the item at issue was needed to expedite wound
healing and prevent an extensive surgical procedure.

The Plan requested a reopen stating the surgical wound for which Cogenex was to be used was not described in
the clinical notes. The surgery had not yet been performed. There was no description of a non-healing wound.
Medical notes state, "plan to excise" and "skin graft versus Cogenex discussed, patient prefers Cogenex.". The
medical records show the enrollee was a then 76-year-old woman with squamous cell carcinoma of the right
lower extremity.

A Derm visit note dated August 11, 2023, documents a diagnosis of squamous cell carcinoma on the right
lower leg. The enrollee was to be referred to plastic surgery or dermatologic surgery. The Surgery Consult
(Lesion) note dated 8/24/2023 documents, "skin graft vs Cogenex discussed patient prefers Cogenex". The
Plan is correct in this case. The clinical documentation is insufficient to support that Cogenex is/was medically
reasonable and necessary for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cogenex amniotic membrane (Q4229) have not been met. Therefore, we
decided that the Plan does not have to provide coverage for Cogenex amniotic membrane (Q4229) for the
enrollee.