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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periodontal 
maintenance (D4910), adjunctive pre-diagnostic testing (D0431) and intraoral x-ray imaging (D0220, D0230) 
provided on October 3, 2020. 
 
You asked the Plan to pay for the dental care provided by an opt-out provider. You say that you were told you 
could choose any dental provider, even if they are not a part of the Plan's network. The Plan denied your 
request. The Plan says services provided by providers who do not participate in Medicare will not be covered. 
The Plan also stated that they reviewed the call logs and found that you did not ask about the provider in 
question and were told that you could see any licensed provider who participates in Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, care provided by providers who do not 
participate in Medicare is not covered under this benefit. We found that this provider opted out of Medicare in 
2015 and was not a participating provider at the time of service. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150), periodontal maintenance (D4910), adjunctive pre-
diagnostic testing (D0431) and intraoral x-ray imaging (D0220, D0230) provided on October 3, 2020 by an 
opt-out provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nourianz.
You asked the Plan to pre-approve Nourianz. You say that this medication is medically necessary for the
enrollee. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nourianz.
Benefits for Nourianz 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
hospital on October 9, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you did not know it would cost so 
much more at the hospital. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
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 $275 
copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital.  
 
You have been asked to pay a $275 copayment for a CT scan. The correct copayment has been applied to the 
services that were provided. A CT scan falls within the outpatient diagnostic tests/advanced imaging 
services/outpatient hospital 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 a CT scan 
provided by a participating hospital on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on October 26, 2020. 
 
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 services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that the enrollee had been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on October 
26, 2020.  
 
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 25, 2020, to June 29, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told your 
insurance covered the hospital stay. The Plan denied your request. The Plan says you have been asked to pay 
the correct cost-sharing amount. 
 
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 $395 
copayment per day for days 1 through 4.  
 
You have been asked to pay a $395 copayment for each day of the inpatient hospital stay. ($395 x 4 = $1,580). 
The inpatient hospital stay falls within the Inpatient hospital care 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 inpatient hospital stay provided from June 25, 2020, to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two porcelain/ceramic retainer crowns (D6740), a pontic porcelain/ceramic prosthodontic (D6245) and a bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says the requested services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 two porcelain/ceramic retainer crowns (D6740), a pontic porcelain/ceramic prosthodontic (D6245) and a bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313), 
attendant control (E2331), push handles (K0108), and a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve an expandable controller, attendant control, push handles, and a power seat 
elevation system. You say that the enrollee needs these items. The Plan denied your request. The Plan says 
these items are not necessary and not covered. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary for a function described in the LCD. Power seat elevation features are non-covered because they are 
not primarily medical in nature. If an attendant control is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-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 an expandable controller, attendant 
control, push handles, and a power seat elevation system. Our reviewer says that the criteria for coverage of the 
requested items have not been met. Our physician reviewer found based on the medical records provided, there 
is no documentation that an expandable controller is medically necessary as the records appear to indicate the 
enrollee has adequate upper extremity strength and function to operate the power options with their own 
switches. The power seat elevation feature and push handles requested are not primarily medical in nature. As a 
beneficiary-operated drive control system has been approved, the attendant control is not necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, attendant control, push handles, and a power seat 
elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377, E2311, E2313), attendant control (E2331), push handles (K0108), and a power 
seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that the evaluation should 
be covered. The Plan denied your request. The Plan says this service is not covered under your supplemental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
limited oral evaluation - problem focused.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray.

You asked the Plan to pay for the intraoral periapical x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 first intraoral periapical x-ray and additional intraoral periapical x-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-
ray (D0220), the unspecified preventive service (D1999), and the sales tax (D9985) provided on October 23, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you needed to get a second opinion. You say 
that you only spent 5 to 8 minutes with the endodontist. You also say that you do not understand why you 
needed another x-ray since your dentist sent one. The Plan denied your request. The Plan says 1 periapical x-
ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that 
limited oral evaluation is not listed as a covered service. The Plan says that unspecified preventive service is 
not listed as a covered service. The Plan says sales tax is not listed as covered either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-rays are listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that 
you received on October 15, 2020. Additionally, the limited oral evaluation, unspecified preventive service, 
and the sales tax are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), the unspecified 
preventive service (D1999), and the sales tax (D9985) provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided 
September 16, 2020. 
 
You asked the Plan to pay for the orthosis. You say that please find the attached documents and reprocess the 
claim towards payment. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation 
and management service and there is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand 
orthosis (L3960) provided September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 26, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative emergency treatment of dental pain (D9110) 
and the unspecified preventive service (D1999) provided on November 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a tooth chip. You say that the pain was 
strong. You say that the dentist performed a temporary fix and advised you needed to see a specialist to 
determine if you needed a root canal. You say that you went to an in network dentist. You also say that you still 
need your teeth worked on. The Plan denied your request. The Plan says personal protective equipment is not 
listed as a covered service. The Plan says that the palliative emergency treatment of pain is considered an 
integral service. The Plan also says that considers payment for the primary procedure to be payment in full for 
the primary and any integral procedures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, unspecified preventive service is not 
among those covered under this benefit. Additionally, payment for a primary procedure is considered to be 
payment in full for a primary and any integral procedures. The record shows that the Plan paid for the limited 
oral evaluation that you received on the date of service. The limited oral evaluation is considered the primary 
service, therefore the integral service, palliative emergency treatment of tooth pain, is not covered. 
 
 Therefore, we decided that the Plan does not have to pay for the palliative emergency treatment of dental pain 
(D9110) and the unspecified preventive service (D1999) provided on November 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
April 14, 2020 to May 12, 2020. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were told that this 
provider was offering virtual visits with no cost-sharing. The Plan denied your request. The Plan says the 
copayment amounts you are being charged are correct. 
 
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 $40 
copayment for each in-network physical therapy visit. There were 9 visits, resulting in a total copayment 
amount of $360. 
 
You have been asked to pay $40 copayment for each physical therapy visit. Physical therapy visits fall within 
the Outpatient Rehabilitation 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 copayments for 
physical therapy visits provided from April 14, 2020 to May 12, 2020.  
 
Your complaint regarding receiving inaccurate information about the cost-share for these services is considered 
to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please 
contact the Plan for more information about your grievance.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was justified. The Plan denied your request. The Plan says that the denial of payment for this inpatient stay is correct, because inpatient level of care was not supported.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was sent from a nursing facility to the emergency department with left hip pain after an unwitnessed fall. No fracture was seen on X-Ray, but right mid-lung infiltrate was seen on chest X-Ray. Low grade fever was noted with blood pressure, pulse oximetry, and respiratory rate falling. She was treated with fluids and antibiotics and was diagnosed with pneumonia. Based on the presentation and emergency department course, it was evidence that the enrollee required hospital services that would likely span at least 2 midnights due to the severity and high risk of complications and fall risk if treated at a lower 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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 pay for critical care services (99291) provided August 12, 2020 to 
August 13, 2020. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not note how 
much time was spent providing this service. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291) provided August 12, 2020 to August 13, 2020.