Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on February 25, 2020.

You asked the Plan to waive the copayment for the breast ultrasound. You say that the cost sharing for this diagnostic procedure should be waived.  You said that you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for radiological diagnostic services. 

You have been asked to pay a $160 copayment for the breast ultrasound. The breast ultrasound falls within the radiological diagnostic services benefit category. Please note that the allowed amount for this procedure is $82.18.  Since the allowed amount is less than your copayment obligation, you are only being charged the allowed amount. 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 breast ultrasound you had on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic shoes and inserts provided on April 20, 2020. You asked the Plan to waive the coinsurance for diabetic shoes and inserts. You say that diabetic shoes and inserts should be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for diabetic supplies and therapeutic shoes. You received diabetic shoes and inserts on April 20, 2020. The total allowed amount is $328.52 and 20% of that is $65.70. You have been asked to pay the total coinsurance amount of $65.70 for diabetic shoes and inserts. Diabetic shoes and inserts fall within the diabetes self-management training, diabetic services and supplies 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 coinsurance for diabetic shoes and inserts provided on April 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that you would like reconsideration 
because the leadless pacemaker is medically necessary. The Plan denied your request. The Plan says the 
member is not in an FDA approved study. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the leadless pacemaker have not been met. Specifically, the record does not indicate that the 
member is in a CMS approved CED study. Therefore, we decided that the Plan does not have to pre-approve a 
leadless pacemaker.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says sensorineural hearing loss is not one of the covered conditions for this service. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the enrollee does not have a condition that is covered for HBO therapy. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Atorvastatin, Carvedilol, and Hydrocodone-Acetamin 
provided on January 30, 2020. 
 
You asked the Plan to pay for the self-administered prescription drugs. You say that the medications were 
needed and the Plan should reimburse what was paid out-of-pocket. The Plan denied your request. The Plan 
says the enrollee's contract did not include prescription drug coverage on the date of service in dispute. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for Atorvastatin, Carvedilol, and 
Hydrocodone-Acetamin provided on January 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 30, 
2020, to June 3, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were misdiagnosed 
and due to the quality of care you received you feel that you should not be responsible for the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $300 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $300 copayment for an inpatient hospital stay. An 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 
an inpatient hospital stay from May 30, 2020, to June 3, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and implant 
supported crown (D6066). 
 
You asked the Plan to pay for the custom fabricated abutment and implant supported crown. You say that an 
implant was already surgically placed last year, and the enrollee is in need of these services in order to 
complete the procedure. The Plan denied your request. The Plan says these services are not covered under the 
enrollee'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 pay for a custom 
fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says occlusal guard 
is not listed as 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard 
(D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator with a non-invasive interface for the 
enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records did not support the medical necessary required to approve this 
request. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
was recently hospitalized with an exacerbation of CHF and COPD, with acute hypercarbic respiratory failure. 
However there is no documentation of CO2 retention while in a stable state. There is no evidence of failure of 
BiPAP. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator with a non-invasive interface for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional complimentary non-emergent transportation 
trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the enrollee needs to continue with doctor's 
appointments. The Plan denied your request. The Plan says any trips over 50 are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that any trips over the 50 allotted by the plan cannot be covered. Therefore, we decided that the Plan does not 
have to pre-approve additional complimentary non-emergent transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo pen inj. 
 
You asked the Plan to pre-approve Forteo (J3110). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Forteo pen inj.  
 
Benefits for Forteo (J3110) 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that you were advised that you need your tooth 
extracted by an oral surgeon. The Plan denied your request. The Plan says dental services are only covered 
when they are performed by a participating general dentist. The Plan also says that dental services performed 
by an oral surgeon 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an extraction provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953 x 8), and an 
unspecified preventive procedure (D1999). 
 
You asked the Plan to pre-approve the 8 bone replacement grafts and unspecified preventive procedure. You 
say that you need these services. You say that you have depression. You say that you struggle to adequately 
take care of your oral hygiene. You also say that you cannot afford to pay for these services on your own. The 
Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says 
unspecified preventive procedure is not listed as a covered service. The Plan also says any services not listed 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve bone replacement grafts (D7953 
x 8), and an unspecified preventive procedure (D1999).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided. 
 
You asked the Plan to pay for the self-administered drugs. You say that the enrollee was hospitalized for 5 
days. You say that the enrollee received eye drops for glaucoma. You say that the enrollee was not able to 
bring his own medications to the hospital nor did he administer them himself. The Plan denied your request. 
The Plan says the drugs that you were provided are considered to be self-administered. The Plan says you have 
a medical only policy, not a Prescription Drug Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered 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 pay for the self-administered drugs 
provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you did not receive dentures on the date of service.
You say that you went to the office that day for a cleaning and an extraction. You also say that now when 
you need a new pair of dentures, the plan will not pay for them. The Plan denied your request. The Plan says 
dentures are covered once every 5 years. The Plan also says that the frequency limit for dentures has been 
reached. 
 
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 dentures are a covered service, the 
frequency limit of once every 5 years has been reached. The record shows that the Plan paid for a complete set 
of dentures that you received in October 2019. Additionally, the Plan contacted the dental office who 
confirmed that you received dentures on that date of service. Therefore, we decided that the Plan does not have 
to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided. 
 
You asked the Plan to pay for the core buildup (D2950). You say that if you didn't need core buildup you 
wouldn't have needed the crown. You say that you were not prepared to pay an additional $352. 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 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 core 
buildup (D2950) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two stair glides. 
 
You asked the Plan to pre-approve two stair glides. You say that this will enable you to safely travel up and 
down both sets of stairs to the toilets and handicap accessible shower. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve two stair glides.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 treatments of root canal obstruction (D3331 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that the dental service is medically necessary. 
The Plan denied your request. The Plan says treatment of a root canal obstruction is not listed as 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 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 3 
treatments of root canal obstruction (D3331 x 3).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on the date of service. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice when the services were provided. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397) and a 
straight knee joint (L2385) provided on the date of service. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because these supplies are medically necessary. The Plan denied your request. The Plan says the records do not 
support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized shipping/billing invoice to verify the supplies billed. Additionally, the 
documentation submitted does not include a proof of delivery for the billed date of service. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397) and a straight 
knee joint (L2385) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for observation, first 15 minutes of deep 
sedation/general anesthesia, and extraction. 
 
You asked the Plan to pay for the office visit, deep sedation/general anesthesia, and extraction. You say that the 
infection under your tooth was spreading into your bloodstream, which would have affected your heart. You 
also say that if the infection had been left untreated, it could have spread to other areas resulting in a potentially 
life-threatening infection. The Plan denied your request. The Plan says you do not have dental coverage. 
 
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 office visit for observation, 
first 15 minutes of deep sedation/general anesthesia, and extraction provided.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on the date of service. 
 
You asked the Plan to pay for ambulance services. You say that the services were medically necessary and not 
related to the hospice diagnosis. 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 ambulance services provided.