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

 
We decided that the Plan does not have to pay for the electrical stimulation provided on June 5, 2023. 
 
You asked the Plan to pay for the electrical stimulation. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says that the electrical stimulation is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that these procedures are considered investigational 
and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by 
underlying systemic diseases.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulation have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulation provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Heelex radiation therapy for the enrollee for
Plantar fascial fibromatosis.

You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment
was medically necessary. The Plan denied your request. The Plan says this treatment is not covered by
Medicare. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not
use the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare does not cover investigational services. The documentation is insufficient
to support that Heelex low-dose radiation therapy is medically reasonable and necessary for the enrollee in this
case or is at least as beneficial as existing and available medically appropriate alternatives. Further
investigation into the potential role in the treatment of the enrollee's condition with modern low-dose radiation
therapy is still required.

Therefore, we decided that the Plan does not have to provide coverage for Heelex radiation therapy for the
enrollee for Plantar fascial fibromatosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for to provide coverage for a single axis, fluid
swing and stance phase control (L5828), a knee-shin system, (L5845), a fluid stance extension, (L5848) and
microprocessor control feature, (L5856) for the enrollee.

You asked the Plan to provide coverage for this prosthetic equipment. You say that this equipment is medically
necessary. The Plan denied your request. The Plan says 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 the notes from the doctor do not give any medical reason why a mechanical K3
knee will not meet this homeless enrollee's needs. The Plan states a microprocessor knee requires more
maintenance, such as maintenance of charge for the battery, and avoidance of water. The microprocessor knee
exceeds the enrollee's needs. The medical records do not show why a mechanical knee cannot be used for the
enrollee's prosthesis.

The Plan also notes a microprocessor knee is more prone to damage and corrosion, especially when exposed to
water. A microprocessor knee requires more maintenance, such as maintenance of charge for the battery, and
avoidance of water. The enrollee is stated to be homeless and at the time of the appeal lived in a homeless
shelter. The enrollee's living environment does not allow the enrollee to provide the required maintenance for
this equipment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare does not cover equipment that exceeds the enrollee's needs.
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 this prosthetic equipment have been
met. Therefore, we decided that the Plan does not have to provide coverage for a single axis, fluid swing and
stance phase control (L5828), a knee-shin system, stance flexion feature, adjustable (L5845), a fluid stance
extension, dampening feature, with or without adjustability (L5848) and microprocessor control feature, swing
and stance phase, includes electronic sensor(s) (L5856).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on June 
29, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says without transport there are no payable 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 29, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and periodontal scaling 
and root planing (D4341) provided on November 15, 2022.  
 
You asked the Plan to pay for periodontal maintenance and periodontal scaling and root planing. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) and periodontal scaling and root planing (D4341) provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 13, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0350) on May 30, 2023. 
 
You asked the Plan to pay for the dental service (D0350). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is 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 pay for the dental 
service (D0350) on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified oral surgery procedure (D7999) provided on July 
7, 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 the services denied correctly as they do not fall 
within your dental 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 pay for 
unspecified oral surgery procedure (D7999) provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 and the supply allowance. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM).. You say that your treating doctor 
recommended the Freestyle Libre 3. The Plan denied your request. The Plan says the denial of authorization for 
the CGM is correct, because the enrollee was provided a CGM in April of 2023. 
 
The Plan must follow Medicare rules. 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 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. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 3 and the supply allowance.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
23, 2023. 
 
You asked the Plan to pay for the ED services. You say that you send additional information to have the claim 
reprocessed. 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 emergency 
department (ED) services provided on July 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the porcelain/ceramic crowns (D2740) 
provided on June 28, 2023. 
 
You asked the Plan to issue additional payment for the dental items. 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 dental items 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 items provided was exhausted on date of service June 28, 2023. Specifically, the 
Plans contract states that the dental benefit provides a $1,000 allowance every year for non-Medicare covered 
preventive dental services and non-Medicare covered comprehensive dental services combined. The Plan 
contract states that you are responsible for any amount above the dental coverage limit. The record shows that 
the Plans responsibility was $184 for the dental services provided on April 19, 2023. The remaining dental 
allowance of $816 was applied to the claim for the dental crowns provided on June 28, 2023. Therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
issue additional payment for the porcelain/ceramic crowns (D2740) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 26, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg with an advanced foot feature
(L5968, L5981).

You asked the Plan to provide coverage for this prosthetic equipment. The Plan denied your request. The Plan
says 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 prosthetist alleges that
member is K3 ambulator. This is not supported by the medical record. While the vendor states that K3
components are medically necessary, the notes from enrollee's physician make no mention of need for K3 foot.
The description of activities does not support the need for a K3 foot. The medical records give no medical
reason why a K2 foot will not meet member's functional needs.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. 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 this
prosthetic equipment have been met as there is no actual medical record documentation to show the enrollee
was a K3 ambulator at the time of the appeal. Therefore, we decided that the Plan does not have to provide
coverage for a prosthetic leg with an advanced foot feature (L5968, L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete upper 
denture (D5110), and a complete lower denture (D5120) provided on July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay the balance. 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 the Plan paid for a comprehensive oral evaluation (D0150), a complete upper denture (D5110), and a 
complete lower denture (D5120) on June 9, 2022; therefore, your benefit for the requested items or services 
was exhausted on the date of service of June 9, 2022. Therefore, we decided that the Plan does not have to pay 
for a comprehensive oral evaluation (D0150), a complete upper denture (D5110), and a complete lower denture 
(D5120) provided on July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 28, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 28, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided June 8, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. 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 code 99223 provided June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture services provided on July 15, 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, and they were medically necessary. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within Plan dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for denture services provided on July 
15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services provided on July 12, 2023. You asked the Plan to pay for ambulance transport services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance transport services provided on July 12, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on July 5, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that it was the home's 
protocol to call an ambulance when there is a fall. The Plan denied your request. The Plan says without 
transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 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 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 27, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crowns and core buildup services (D2740, D2950) 
provided on June 13, 2023. 
 
You asked the Plan to pay more 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 13, 2023. Therefore, 
we decided that the Plan does not have to pay more for a crown and core buildup services (D2740, D2950) 
provided on June 13, 2023.