Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the screening digital breast tomosynthesis and the screening 
mammography services received on August 31, 2020. 
 
You asked the Plan to pay for the screening digital breast tomosynthesis and the screening mammography 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says that these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the case file submitted by the Plan to Maximus 
was largely incomplete. The case file was missing required documentation such as The Plan?s Reconsideration 
Decision and the Case Summary for this case. The documentation does not show why these services were 
denied. In addition, Maximus requested this information from the Plan twice without response. Therefore, we 
decided that the Plan has to pay for the screening digital breast tomosynthesis and the screening mammography 
services received on August 31, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and panoramic x-ray 
provided on November 5, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray. You say that you 
were told that you had good dental insurance coverage, but nothing was covered. The Plan denied your request. 
The Plan says these services are not covered benefits. 
 
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 
complete series of intraoral x-rays and panoramic x-ray provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) and 
prefabricated abutment (D6056) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has been without teeth for months 
and is now experiencing weight loss. The Plan denied your request. The Plan says these services are not 
covered under the member's benefit package. 
 
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 the 
surgical placement of implant body (D6010) and prefabricated abutment (D6056) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), periapical x-ray (D0220, the 
bitewing x-rays (D0272), and prophylaxis (D1110) provided on September 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were denied because your dental 
coverage was terminated on August 31, 2019. You say that you set up the payment to come directly out of your 
Social Security check. You say that you did not authorize anyone to stop making these payments. You say that 
this bill is a financial burden on you. You also say that you did not know that payments were not being made as 
you only get a print out at the end of the year. The Plan denied your request. The Plan says your dental 
coverage was terminated on August 31, 2019. The Plan says that the services you received are routine dental 
services. The Plan also says that routine dental services are not covered. 
 
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 the oral exam (D0120), 
periapical x-ray (D0220, the bitewing x-rays (D0272), and prophylaxis (D1110) provided on September 24, 
2020.  
 
Your complaint about being disenrolled from your dental coverage without your knowledge is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
July 31, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 31, 2020. 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 services provided July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the fillings provided on August 27, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that when you signed up for this 
coverage, you were told that you could go to whoever you wanted to. You say that the dentist never told you 
that they did not accept Medicare. You also say that once you submitted proof of payment, you should be paid. 
The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also 
says that payment cannot be made to providers who have opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the fillings provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has deluxe features that exceed your need and replaces, rather than improves 
the function of the arm. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the literature is insufficient in terms of effectiveness and safety of this device for the enrollee's condition. 
At this time the requested orthosis is not proven to be more beneficial for treatment of the enrollee's medical 
condition than any available standard therapy. There is insufficient literature in the peer reviewed publications 
to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro 
Orthosis for upper extremity paralysis/paresis from conditions such as the enrollee's brachial plexus injury, or 
other neuromuscular/neurological disease or injury. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first 
intraoral periapical x-ray provided on August 6, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that the Plan made the appointment for you with this provider. You also say that you should not have 
to pay for these services. 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 
problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on February 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer's 
EOB is required. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services you received on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested device is considered experimental. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy. Also, there is no spinal instability 
documented and hardware is not needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion Device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on March 10, 2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says the Plan requires utilization of network providers when possible and available, and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented. 
 
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 
services at issue. 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 a psychiatric diagnostic evaluation with medical services 
provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic and two retainer crowns provided on September 8, 
2020. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that the remainder of your bill is to be 
covered by the Plan. You also say that crowns are a covered benefit under your plan. 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 pontic 
and two retainer crowns provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an automatic external defibrillator provided August 
5, 2020. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you should 
not have to pay the coinsurance. The Plan denied your request. The Plan says that the claim was processed 
correctly toward your maximum out-of-pocket limit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 20% coinsurance at a durable medical equipment provider. 
The Plan contract also says that your in-network maximum out-of-pocket amount is $1,000.00. 
 
The Plan says you must pay 20% coinsurance for an automatic external defibrillator. Based on the Plan 
contract, however, you cannot be asked to pay more than $1,000 out-of-pocket. The Plan provided 
documentation that the out-of-pocket maximum had already been met when the claim was processed. 
Therefore, we decided that the Plan has to waive the coinsurance for the DME provided August 5, 2020.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 3,2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee self-referred out of network 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 pay 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 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 out of network 
physician services provided to the enrollee on December 3,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam and periapical x-rays rendered 
on August 21, 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 exam exceeded the benefit limit and the x-rays 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. The Plan covers one 
comprehensive oral exam every three years. Periapical x-rays are not covered.  
 
The file shows that you received a comprehensive oral exam and periapical x-rays on August 21, 2020. You 
previously had a comprehensive oral exam on April 18, 2018 for which the Plan approved and paid. The 
services on August 21, 2020 were performed less than three years from your previously covered exam. The 
periapical x-rays are not covered by your supplemental dental benefit or your medical benefit. 
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam and periapical x-rays 
rendered on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A Continuous Positive Airway Pressure (CPAP) 
machine and supplies (A7038, A7037, A7034, A7035). 
 
You asked the Plan to pre-approve the CPAP. You say that you require a new CPAP machine The Plan denied 
your request. The Plan says you do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that you must meet certain medical criteria and the 
documentation must show these criteria, including excessive daytime sleepiness, impaired cognition, mood 
disorders, or insomnia or, hypertension, ischemic heart disease, or history of stroke. You must have a valid 
sleep test. And you must be reevaluated after five years if a replacement is needed.  
 
The clinical information provided with the request did not indicate excessive daytime sleepiness, impaired 
cognition, mood disorders or insomnia, hypertension, ischemic heart disease (a disease that causes narrowing 
of the coronary arteries), or history of stroke. In addition, as per the sleep study from 2016 the AHI is not 
consistent with CMS guidelines (L33718) and a new sleep study is required. Furthermore, the Plan contacted 
you to assist in scheduling an appointment to see a pulmonologist for a new sleep study however, you declined 
to see a pulmonary physician. The Plan has no authorizations or claims on file for any CPAP supplies.  
Therefore, the request for an authorization for a continuous positive airway pressure (CPAP) machine and 
supplies has been denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP have not been met. Therefore, we decided that the Plan does not have to pre-approve A 
Continuous Positive Airway Pressure (CPAP) machine and supplies (A7038, A7037, A7034, A7035).