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

We decided that the Plan does not have to pay for three additional resin-based composites and intraoral x-rays 
provided on May 19, 2020, and May 29, 2020. 
 
You asked the Plan to pay for three additional resin-based composites and intraoral x-rays. You say that x-rays 
were required to determine the damage done in order to repair the teeth. You say that the claims should not be 
denied. The Plan denied your request. The Plan says the frequency limitation has been exceeded for the resin-
based composites and the intraoral x-rays 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, you also have a maximum benefit of 
one amalgam or composite restoration per calendar year. The Plan paid for one resin-based composite provided 
on May 20, 2020, which exhausted your benefit. The intraoral x-rays are not covered benefits. Therefore, we 
decided that the Plan does not have to pay for three additional resin-based composites and intraoral x-rays 
provided on May 19, 2020, and May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal X-ray (74022) performed on 
June 30, 2020. 
 
You asked the Plan to waive the copayment for an abdominal X-ray. You say that this service was for 
diagnostic purposes. The Plan denied your request. The Plan says the correct copayment was 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 $95 
copayment for basic radiological services at an outpatient hospital.  
 
You have been asked to pay a $95 copayment for an abdominal X-ray. An abdominal X-ray falls within the 
"Outpatient diagnostic tests and therapeutic 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 copayment for an abdominal X-ray (74022) performed on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the prophylaxis, periodic oral evaluation and unspecified preventive 
procedure provided on May 26, 2020. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and unspecified preventive procedure. 
You say that you searched the online directory and found the dentist listed at in-network. You say that 
everything you found online indicated his services would be eligible under the dental benefit. The Plan denied 
your request. The Plan says that payment cannot be issued for services performed by a provider who has opted 
out of Medicare. 
 
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. Our review of the Medicare database does not indicate the provider has opted 
out of Medicare. The Plan did not submit any legible documents showing the provider was an opt out provider 
at the time of service. Therefore, we decided that the Plan has to pay for the prophylaxis, periodic oral 
evaluation and unspecified preventive procedure provided on May 26, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services required by the enrollee 
exceeds the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care, and does not require transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the current acute care hospital with acute respiratory failure 
related to pneumonia and septic shock. He was treated with oxygen, steroids, vasopressors, and antibiotics. 
Acute kidney injury was diagnosed but resolved recently. Recent notes show that he is improving with stable 
vitals on nasal cannula oxygen supplementation. The enrollee appears to be more stable and requires less than 
an additional 25 days of acute care services. The enrollee does not require services at the LTACH that are not 
already available at the current setting. Therefore, this request is not medically necessary at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 30, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cystoscopy, with injection(s) for 
chemodenervation of the bladder (52287) onabotulinumtoxina (Botox) injection (J0585) provided June 15, 
2020. 
 
You asked the Plan to waive the copayment for outpatient surgical procedure. You say that you had these shots 
for the last 7 years and only paid $275 for outpatient surgery center and nothing more. The Plan denied your 
request. The Plan says the claim was processed with the correct cost shares 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 $275 
copay for surgical service in an ambulatory surgical center and 20% coinsurance for Medicare covered Part B 
covered drugs for Medicare Part B prescription drugs and Outpatient surgery, included services provided at 
hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $526.73 for the outpatient surgical procedure. The outpatient surgical procedure 
falls within the Medicare Part B prescription drugs and Outpatient surgery, included services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit categories. 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 cystoscopy, with injection(s) for 
chemodenervation of the bladder (52287) onabotulinumtoxina (Botox) injection (J0585) provided June 15, 
2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for transport services provided to the enrollee on April 17, 2020. 
 
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 due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
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 
transport services provided to the enrollee on April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided February 15, 2020 
to March 15, 2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that the oxygen equipment was medically 
necessary. The Plan denied your request. The Plan says insufficient documentation has been provided to 
support the need for the oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due.  
 
We looked at the file and Medicare rules. Only a single page of clinical documentation was provided to the 
plan. The plan requested additional medical records and none were provided. Based on this information, we 
decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided 
that the Plan does not have to pay for an oxygen concentrator (E1390) provided February 15, 2020 to March 
15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services from May 3, 2020, through May 6, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you needed SNF care. The Plan denied your 
request. The Plan says SNF coverage was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the SNF services from May 3, 2020, through May 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B 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 pre-approve Ondansetron.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit with 
injection (99213, 20610, J0702) provided on July 8, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit with injection. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 has network providers 
available who can provide 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 the established patient office or other outpatient 
visit with injection (99213, 20610, J0702) provided on July 8, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the prediagnostic testing (D0431) and the 
preventive service (D1999) provided on May 19, 2020. 
 
You asked the Plan to pay the in network rate for the prediagnostic testing and preventive service. You say that 
you made an appointment with an in network provider. You say that on the day of your appointment you were 
seen by another dentist. You also say that you feel that you were deceived by the provider's office. The Plan 
denied your request. The Plan says the preventive service and prediagnostic testing are not listed as 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 prediagnostic testing and 
preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay the in network rate for the prediagnostic testing (D0431) and the preventive service (D1999) 
provided on May 19, 2020.  
 
Your complaint about being deceived by the provider's office 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup (D2950) provided on January 20, 2020. 
 
You asked the Plan to pay for core buildup (D2950). You say that you were informed everything would be 
covered. 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 core 
buildup (D2950) provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-rays provided on June 9, 2020. 
 
You asked the Plan to pay for the additional intraoral x-rays. You say that you haven't been getting coverage 
from your plan. You say that you were told the provider is covered. The Plan denied your request. The Plan 
says the frequency limitation has been exceeded. 
 
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, you also have a maximum benefit of 
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 9, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-
rays provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on June 
30, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this exam was for a 
chipped tooth, and not for a regular visit. The Plan denied your request. The Plan says you had already 
exhausted your oral exams benefit. The Plan also says that you were not eligible for an additional exam. 
 
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, oral examinations are limited to two 
per calendar year. The record shows that you received oral examinations on February 7, 2020, and February 18, 
2020, and your oral examinations benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the problem focused limited oral evaluation provided on June 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a 
participating provider on April 26, 2020. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you don't feel like you 
should be responsible because you went right into surgery. 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 $120 
copayment for emergency care/in-network/emergency services.  
 
You have been asked to pay a $120 copayment for emergency room services. Emergency room services fall 
within the emergency care/in-network/emergency 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 copayment for emergency room services provided by a participating provider on April 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for three emergency room (ER) visits you had 
from June 4, 2020, to June 20, 2020. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you had to go to the ER three times 
because your primary care provider made mistakes with your thyroid medication. The Plan denied your 
request. The Plan says you were charged these copayments 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 an $80 
copayment per visit for emergency care.  
 
You have been asked to pay an $80 copayment per visit for the ER visits. This copayment obligation applies 
regardless of the reason for the ER visits. 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 three 
emergency room (ER) visits you had from June 4, 2020, to June 20, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion/arthrodesis for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the indicated type of pain. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no instability, fracture, or lesion. There is severe neurological deficit. The surgery is not 
needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion/arthrodesis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve jaw reconstruction. 
 
You asked the Plan to pre-approve jaw reconstruction. You say that reconstruction is required to prepare the 
area for a dental implant. You say that the dental implant in piece #6 is required to restore bite, function and 
speech. 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 pre-approve jaw 
reconstruction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L1971, L3170) provided on April 6, 2020. 
 
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied 
your request. The Plan says there is not a valid proof of delivery for this service. 
 
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. The invoice in the 
file only lists one of the items at issue, and neither it nor the delivery ticket show the billed date of service as 
the shipping or delivery date. 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 orthotics (L1971, 
L3170) provided on April 6, 2020.