Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit option (K0108). 
 
You asked the Plan to pre-approve transport option. You say that please reconsider the documentation provided 
for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. The Plan 
denied your request. The Plan says items that are used outside of the home are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transport option have not been met. Therefore, we decided that the Plan does not have to pre-approve transit option (K0108).
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 its unsafe for you to go home with the 
type of care you need. You require daily physician and pharmacist monitoring for management of antibiotics to 
prevent eradication of infection. The Plan denied your request. The Plan says your care can be provided at a 
lower level of care like skilled nursing or in home with home health. Your wound vac is changed three times a 
week and there is no other medical service required. 
 
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 recent notes describe your wound as healing and you were alert with stable vitals. 
You appear to be more stable and improving with current treatment and should only require short-term 
additional acute care services that can safely be administered at the current facility until appropriate for a lower 
level of care. You do not require services at the LTACH that are not already available at the current facility. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility for the enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is being requested for skilled therapy. The 
Plan denied your request. The Plan says there is no need for more skilled therapy or more complicated medical 
care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper denture (D5110), lower denture (D5120) and 
unspecified prosthodontic procedure (D5899) provided on December 30, 2021. 
 
You asked the Plan to pay for the upper denture, lower denture and unspecified prosthodontic procedure. You 
say that you would like reconsideration because you needed new dentures and were told you could see any 
dentist as long as they accept Medicare. The Plan denied your request. The Plan says you used the $1,000 
allowance on this date of 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, you are responsible for any 
amount over your $1,000 allowance. The record shows that the Plan paid $1,000 towards your dentures. 
You are responsible for the remaining balance. Therefore, we decided that the Plan does not have to pay 
for the upper denture (D5110), lower denture (D5120) and unspecified prosthodontic procedure (D5899) 
provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from September 20, 2021, 
through October 18, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says there is no 
documentation from the provider with treatment provided, indications, and response to treatment. 
 
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 and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of acupuncture treatment provided by 
from September 20, 2021, through October 18, 2021 have been met. Although the Plan made multiple attempts to obtain additional information from this provider, no additional information and records were received to 
confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to 
pay for acupuncture treatment provided from September 20, 2021, through October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital services provided on December 8, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Hospital 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 Hospital services provided on December 8, 2021 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 12, 2022. 
 
You asked the Plan to pre-approve SNF care after May 12, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
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 in the Medicare rules section 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 pre-approve SNF care after May 12, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found you do not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF 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 SNF care after May 12, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on April 29, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing services have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the genetic testing services provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the over-the-counter Covid-19 test.

You asked the Plan to pre-approve the over-the-counter Covid-19 test. You say that this item should be covered. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that plans may choose to offer some benefits to enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are required to offer if the item or service also meets the criteria described in sections 30 and 40 of this chapter.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the over-the-counter Covid-19 test have not been met. Therefore, we decided that the Plan does not have to pre-approve the over-the-counter Covid-19 test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you told the dental office 
that you did not want any services to be rendered that would not be covered. The Plan denied your request. The 
Plan says your benefits for this service have been satisfied and 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 19, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the additional intraoral periapical x-ray (D0230) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an 
out-of-network provider on January 19, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you did not know the 
dentist was out-of-network and now you owe $162. You say that you want to stay with this provider. The Plan 
denied your request. The Plan says out-of-network services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation and prophylaxis provided by an out-of-network provider on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show an exam showing that this equipment is able to be used. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
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 scooter. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided, there is no documentation that you have a personal mobility 
deficit that impairs participation in mobility-related activities of daily living such as toileting, feeding, 
grooming and bathing in customary locations within the home. A medical note of 12/21/2021 reports that you are independent with ambulation/transfers. There is no documentation that your mobility deficit cannot be 
helped by the use of a walker, cane or manual wheelchair. There is no documentation showing that you would 
be able to safely operate the scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27279). 
 
You asked the Plan to pre-approve the procedure. You say that you need to have this surgery. You have fallen 
in the shower 4 times. You do not have any pain pills and you think physical therapy and another injection will 
be a waste of money. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for medical necessity. 
 
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 procedure. 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 imaging of the sacroiliac joint (SIJ) or pelvis or hip. The enrollee refuses physical 
therapy. There is no documentation the enrollee has tried bracing or targeted home exercises. The enrollee did 
not have any reported improvement in his pain with one SIJ injection. The enrollee does NOT meet the criteria 
for fusion and the request is not medically reasonable or necessary. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint fusion (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from April 19, 2021, to April 
22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient services. You say that due to the nature of the visit you feel you 
should not be held responsible for the payment. The Plan denied your request. The Plan says the services 
provided were rendered at a non-contracted facility and were not authorized by the Plan prior to the visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 inpatient services provided from April 19, 
2021, to April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer for resin bonded fixed prosthesis (D6549) for 
tooth # 22. 
 
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied 
your request. The Plan says retainer for resin bonded fixed prosthesis 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested retainer for resin bonded 
fixed prosthesis is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve retainer for resin bonded fixed prosthesis (D6549) for tooth # 22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper right quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says gingival irrigation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for the upper right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oral device/appliance (E0486) 
provided on October 6, 2021. 
 
You asked the Plan to waive the coinsurance for the oral device/appliance. You say that you are incorrectly 
being charged for this device. The Plan denied your request. The Plan says this date of service was only for a 
measuring and fitting. You also say that you did not receive the device until January 6, 2022 when your 
insurance was in place, and it should be covered. 
 
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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies for Durable 
medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the oral device/appliance. The oral device/appliance falls 
within the Durable medical equipment (DME) and related 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 the oral device/appliance (E0486) provided on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allogeneric cellular allograft. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that stem cell transplant is covered for specific 
indications only. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of the requested allograft is 
considered experimental/investigational in nature for the use in degenerative back surgery. More research is 
needed to show its safety and effectiveness. The services are therefore not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an allogeneric cellular allograft.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit provided on December 21, 2021.
You asked the Plan to pay this claim. You say that this visit should be paid by the Plan. The Plan denied your
request. The Plan says the enrollee was under hospice election at the time of service. Maximus overturned the
Plans denial for lack of hospice confirmation in the file. The Plan requested a reopen and provided the required
documentation.
The Plan is correct in this case. 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 Plan provided documentation to show the enrollee was under the Medicare hospice benefit on the date of
service. This claim must be submitted to Original Medicare first for review. Therefore, we decided that the
Plan does not have to pay for a patient domiciliary, rest home visit provided on December 21, 2021.