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

 
We decided that the Plan does not have to pre-approve a dental crown (D2740), a core buildup (D2950), and a 
resin-based composite (D2393). 
 
You asked the Plan to pre-approve dental codes D2740, D2950, and D2393. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D2740 and D2950 are 
not covered under the Plan's supplemental dental benefit. Fillings, D2393, are limited to 2 procedures per 
calendar year. You were approved for 2 fillings for tooth # 7 and 8 on June 2, 2022, therefore a request for 
fillings on tooth # 4 and 11 exceeds your benefit limitation. 
 
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, dental codes D2740 and D2950 are not 
among those covered under this benefit. Your contract with the Plan says fillings, D2393, are limited to 2 
procedures per calendar year. You were approved for 2 fillings for tooth # 7 and 8 on June 2, 2022, therefore a 
request for fillings on tooth # 4 and 11 exceeds your benefit limitation. Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2740), a core buildup (D2950), and a resin-based composite (D2393).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a screening retinopathy exam, retina 
imaging, and an ophthalmoscopy provided on February 28, 2022. 
 
You asked the Plan to waive the copayment for retina imaging and an ophthalmoscopy. You say that you have 
diabetes, and this was a screening exam. The Plan denied your request. The Plan says you have been charged 
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 $75 
copayment for in-network diagnostic procedures and tests.  
 You have been asked to pay the allowed amount of $33.97, which is less than the $75 copayment for retina 
imaging. You have also been asked to pay $6.03, which is less than the $75 copayment for an ophthalmoscopy. 
Retina imaging and an ophthalmoscopy 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 a screening retinopathy 
exam, retina imaging, and an ophthalmoscopy provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a canal preparation and fitting of preformed dowel or 
post (D3950). 
 
You asked the Plan to pre-approve the canal preparation and fitting of preformed dowel or post. You say that 
you need this service approved for coverage. The Plan denied your request. The Plan says this service is not 
covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
canal preparation and fitting of preformed dowel or post (D3950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implants (D6010) and prefabricated abutments 
(D6056) for teeth #21 and #28, and a surgical stent (D5982). 
 
You asked the Plan to pre-approve dental implant services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical implants (D6010) and prefabricated abutments (D6056) for teeth #21 and #28, and a surgical stent 
(D5982).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010 x 4), custom fabricated 
abutment (D6057 x 4), replacement of semi-precision or precision attachment (D6091 x 4), and abutment 
supported removable denture (D6111). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. You 
also say there is no other option to restore the enrollee's ability to chew properly. The Plan denied your request. 
The Plan says the requested services are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010 x 4), custom fabricated abutment (D6057 x 4), replacement of semi-precision or 
precision attachment (D6091 x 4), and abutment supported removable denture (D6111).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the critical care, first hour (99291) and critical care, each additional 30 
minutes, (99292) provided August 11, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the critical care procedure has been denied 
as incidental to CPR. Please review the attached emergency department notes and consider processing for 
payment. The Plan denied your request. The Plan says that payment for the critical care were included in the 
payment for cardiopulmonary resuscitation CPT code 92950. 
 
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, first hour and 99292 is critical care, each additional 30 minutes. 
 
We asked our coder 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 critical care services. Our reviewer says that the criteria 
for coverage of the critical care services was met. Our reviewer found the documentation describes, "code blue" 
was called at 15:12 while in radiology department and transferred back to emergency department.  The 
physician clearly documents critical care performed for an unstable patient for 120 minutes. This procedure 
would not be inclusive to CPT 92950. Therefore, CPT 99291 and CPT 99292 should be covered, in addition to 
CPT 92950. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the critical care services have been met. Therefore, we decided that the Plan has 
to pay for the critical care, first hour (99291) and critical care, each additional 30 minutes, (99292) provided 
August 11, 2021.  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pay for out of area services provided on August 30, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says that this provider was not in network. Maximus upheld the Plans
denial. Upon further review, Maximus reopened the case due to a process error.
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. There were no medical records submitted with the case file that
would allow us to determine this situation was not urgent our emergent while out of area and/or out of network.
Therefore, we decided that the Plan has to pay for out of area x-rays of the ankle provided on August 30, 2021.
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 pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that you need new dentures and have not been 
able to properly eat without them. The Plan denied your request. The Plan says you previously received a set of 
complete dentures on October 23, 2019, which were covered by the Plan. Complete dentures are covered once 
per jaw every five years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's dental benefit 
covers one complete upper denture (D5110) every five plan years and one complete lower denture (D5120) 
every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the 
dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that you lost your previous dentures and need 
replacements. The Plan denied your request. The Plan says you previously received a complete upper denture 
(D5110) and partial lower denture (D521) on May 10, 2021. These items are only covered once within a five-
year period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract states that 
the dental benefit can cover up to one lower partial denture, cast metal framework with resin denture base 
(D5214) every five plan years and one complete upper denture (D5110) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that these 
dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve additional transportation. You say that both of your legs have been 
amputated, you use an electric chair, and you cannot be taken by car to dialysis 3 times per week. The Plan 
denied your request. The Plan says you have exhausted the established benefit of 24 one-way trips. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 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 you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional wheelchair van transportation (A0130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #20. 
 
You asked the Plan to pre-approve the crown. You say that it is medically necessary for you to receive this 
crown and you feel the service should be covered. The Plan denied your request. The Plan says you have 
reached the benefit maximum. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 2 caps (or crowns) 
per year. The record shows that you received crowns (D2740) on tooth #'s 2 and 4 on February 17, 2022 and 
your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and an abutment supported 
crown (D6058). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom abutment (D6057) and an abutment supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 3, 30, and 31. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says this service is 
allowed two times per calendar year. The Plan also says that the enrollee has reached the limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to two per calendar 
year. The record shows that the enrollee received crowns (D2740) on tooth #'s 26 and 27 on April 5, 2022 and 
the enrollee's crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve crowns (D2740) for tooth #'s 3, 30, and 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says D6010 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient observation stay provided from 
November 24, 2021, to November 30, 2021.  
 
You asked the Plan to waive the copayment for an inpatient observation stay. You say that the doctors could 
not find out what was wrong, so they kept you in the hospital. The Plan denied your request. The Plan says you 
have been charged 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 $200 
copayment for an inpatient observation stay.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$200 copayment for an inpatient observation stay. An inpatient observation stay falls within the Outpatient 
Hospital Observation 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 
observation stay provided from November 24, 2021, to November 30, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 You asked the Plan to pre-approve the compression stockings. You say that you require compression 24/7. The 
Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4267) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
guided tissue regeneration (D4267) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to 
metal crown. You say that you were approved for implants in 2021. You also say that you need the caps to be 
placed on the screws that were placed, but the caps are being denied. The Plan denied your request. The Plan 
says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth # 7. 
 
You asked the Plan to pre-approve the dental service. You say that the dentist advised the enrollee needs this 
service. The Plan denied your request. The Plan says clinical crown lengthening is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested clinical crown 
lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve clinical crown lengthening (D4249) for tooth # 7.