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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the cervical spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there are few details 
concerning his neck pain, but physical exam showed no red flag to mandate immediate MRI of the cervical 
spine without a 6 week trial of conservative management including physical therapy. The neurological exam is 
normal of the upper extremities and normal reflexes. There is no plain film report of the cervical spine in the 
records. Absent the demonstration of medical necessity for the requested MRI of the cervical spine the exam 
cannot be approved. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital facility services 
provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital facility services. You say that you were not 
expecting to get charged. The Plan denied your request. The Plan says the copayment was applied 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 $350 
copayment per visit for outpatient hospital facility services. 
 
 
  You have been asked to pay only the allowed amount of $58.87 which is less than the standard copayment for 
outpatient hospital facility services. Outpatient hospital facility services falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient hospital facility services provided on January 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office visit provided on October 28, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office visit. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
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 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 Office visit provided on October 28, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2740) provided on January 18, 2022. 
 
You asked the Plan to pay for dental code D2740. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the 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, dental code D2740 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services 
(D2740) provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient signed financial forms that they had 
Medicare, and charges were billed to Medicare. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider, and there is no referring provider involved in these services. The Plan 
also says that they did not authorize any services for this provider. 
 
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 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 an office visit provided on March 3, 2021, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says you have used all 20 allowed one-way 
trips for the 2022 benefit year. 
 
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 20 one-way transportation 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 routine transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for all items and services provided from 
January 14, 2021, to October 31, 2021. 
 
You asked the Plan to waive the cost sharing for the items and services. You say that an insurance 
representative wrongly signed your father up for a managed Medicare Plan for 2021. 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). The enrollee's contract with the Plan clearly says what the enrollee 
must pay for each item or service.  

This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost sharing for all items and services provided from January 
14, 2021, to October 31, 2021.  

Maximus Federal Services read your letter and knows that you may have a question regarding your enrollment 
in the Plan. Maximus Federal Services cannot answer enrollment questions. Maximus Federal Services is 
sending a copy of your case file and your letter to the CMS Regional Office so that it can look into your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraoperative radiation therapy.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested treatment is not supported for the enrollee's cancer type.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time, there is insufficient information to support the use of intraoperative radiation therapy for breast cancer over alternative treatment regimens. Based on the available studies and evidence-based guidelines, intraoperative radiation therapy for early stage breast cancer is currently considered investigational. The treatment regimen is not recommended outside of a clinical trial.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intraoperative radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that athletic trainers are not considered qualified therapy 
professionals and may not bill their services under the Medicare therapy benefit. 
 
We looked at the file and Medicare rules. The file shows that the requested provider is an athletic trainer. 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 chiropractic services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87491, 87591, 88142) rendered by 
the out-of-network (OON) provider on January 11, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, 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 services at issue in this appeal. 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 the laboratory services (87491, 87591, 88142) rendered by the out-of-network 
(OON) provider on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis, cleaning (D1110) complete series x-rays 
(D0210) panoramic x-rays (D0330) provided December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office told you that they were in 
network with the Plan. The Plan denied your request. The Plan says the claim has been processed with the 
correct cost share applied per the Evidence of Coverage. 
 
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 50% for 
out of network dental services.  
 
You have been asked to pay $249.00 ($62 coinsurance + $187 benefit exclusions) for the dental services. The 
contract says that benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than 
the payment made by Plan to the provider. The services fall within the Dental 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 pay for prophylaxis, cleaning (D1110) complete series x-rays (D0210) panoramic x-
rays (D0330) provided December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) and the nail debridement (11721) rendered by an out-of-network 
(OON) provider on March 16, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, 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. 
 
 You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the services at issue in this appeal. 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 the domiciliary or rest home visit for the evaluation and management of an established patient 
(99334) and the nail debridement (11721) rendered by an out-of-network (OON) provider on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the consultation (D9310) with an oral surgeon provided on January 21, 2022. 
 
You asked the Plan to pay for the consultation. You say that this service should be paid under your medical 
benefit. The Plan denied your request. The Plan says that the 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. We received additional information from the enrollee that requests dental code 
D9310 be paid under the enrollee's medical benefit and not under the dental benefit. The enrollee received this 
consultation with an oral surgeon for the evaluation of the possibility of cancer on the upper hard palate, which 
is part of the facial skeleton. The Plan provided no medical records in order to determine if the services were 
medical in nature. We find that the Plan has not provided sufficient evidence to show that their denial of 
payment is based on Medicare criteria. Therefore, we decided that the Plan has to pay for the consultation 
(D9310) with an oral surgeon provided on January 21, 2022.  
 
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 dental services (D7953) provided on November 18, 2021. 
 
You asked the Plan to pay for dental code D7953. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the 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, dental code D7953 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services 
(D7953) provided on November 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 9, 2021, through November 16, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $200 per 
day, for days 1-5 and $0 after day 5, each time you are admitted to an acute care hospital.  
 
 You have been asked to pay $1,000 ($200 copayment x 5 days) for the inpatient hospital care provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital care provided from November 9, 2021, 
through November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiology services provided on January 4, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Radiology services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 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 Radiology services provided on January 4, 2022 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided February 11, 2021. 
 
You asked the Plan to pay for the additional intraoral x-ray. You say that your services should have been 
processed as in-network. The Plan denied your request. The Plan says your claim for this date of service have 
been reprocessed as in-network. The third intraoral x-ray is not covered because it exceeds frequency limits. 
 
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 the additional 
intraoral x-ray once per plan year.  
 
We looked at the file and Medicare rules. The Plan has covered two intraoral x-rays on the same date of 
service. Based on this information, we decided that the Plan's frequency limit for coverage of the additional 
intraoral x-ray has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical each additional radiographic image (D0230) provided February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services provided on December 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for angiography services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says you are a non-contracted provider with the Plan, and they do not 
have record that your facility requested a benefit certification from them prior to rendering the service which 
was neither urgent nor emergent in nature. The Plan also says that this denial is not a matter of medical 
necessity, and it is a matter of their prior authorization guidelines and the member's benefit plan. 
 
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 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 angiography services provided on December 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 48 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 routine transportation.