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

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the
enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF care was
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the records show the enrollees
care was primarily custodial, which is not covered by Medicare.
The Plan is correct in this case. 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. The
records provided were quite limited. They show no requirement for daily skilled nursing services required on
an inpatient level of SNF care. They show some therapy services were required, again not at the level of an
inpatient admission. The majority of the care needed at the time of the appeal was custodial due to the enrollees
living condition. Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the
Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service August 13, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99291 is bundled into 
payment for code 47600. 
 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, we have confirmed that code 99291 
is a column II code to column I code 47600. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 billed for date of service August 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AC mode with low tidal 
volumes that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently hospitalized. There is insufficient evidence of effectiveness of this device in the treatment of COPD. It 
is not a true ventilator because it is not capable of providing full ventilatory support. There is no documentation 
of chronic CO2 retention with ABG while stable, so the enrollee does not meet criteria for ventilatory support 
during sleep. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided on June 13, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies should be covered. The Plan denied your 
request. The Plan says the provider did not discuss the need for the supplies in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that for DMEPOS items and supplies provided on a 
recurring basis, billing must be based on prospective, not retrospective use. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies, 2 lead, per month (A4595) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc percutaneous injection of human disc tissue 
into the lumbar spine (0627T). 
 
You asked the Plan to pre-approve the injection. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered experimental and investigational. Therefore, the reviewer found that the 
requested injection is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA disc percutaneous injection of human disc tissue into the lumbar spine (0627T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested 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 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 pay for the dental 
services on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (0089U) provided on April 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the pathology services (0089U) provided on April 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary arch reconstruction and future placement of 6 
implants. 
 
You asked the Plan to pre-approve dental services. You say that the services requested for the enrollee are 
needed. The Plan denied your request. The Plan says this service is not covered under your 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. Maxillary arch reconstruction 
and future placement of 6 implants are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested maxillary arch 
reconstruction and future placement of 6 implants are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pre-approve maxillary arch reconstruction and future placement of 6 
implants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital admission from December 
8, 2022, forward. 
 
You asked the Plan to pre-approve continued inpatient hospital admission from December 8, 2022, forward. 
You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
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 continued inpatient hospital admission 
from December 8, 2022, forward. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates the 
enrollee was medically stable from December 8, 2022, and forward. The documentation doesnt support that it 
was medically necessary for the enrollee to remain in the inpatient setting to receive further treatment from 
December 8, 2022, and forward. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient hospital admission from December 8, 2022, forward have 
not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital 
admission from December 8, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has obesity-hypoventilation syndrome, and was recently hospitalized after a fall and 
broken ribs. Arterial blood gases (ABGs) were consistent with acute on chronic hypercarbic respiratory failure. 
This enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an outpatient. But 
Medicare does not cover a home ventilator when used as BiPAP, or for the diagnosis of obesity hypoventilation syndrome (OHS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upper partial denture (D5213 and a lower partial denture 
(D5214) provided on April 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the dental 
services. The Plan denied your request. The Plan says your annual dental benefit maximum for the year has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your annual dental benefit maximum for the year was exhausted on the date of service of April 8, 2022. 
On January 12, 2022, the Plan paid $510 for dental services. On January 21, 2022, the Plan paid $176 for 
dental services. On January 27, 2022, the Plan paid $386 for dental services. On February 23, 2022, the Plan 
paid $140 for dental services. On April 8, 2022, the Plan paid $788 for dental services. On April 8, 2022, the 
total amount the Plan paid for yearly dental services was $2,000 ($510 paid + $176 paid + $386 paid + $140 
paid + $788 paid). Therefore, we decided that the Plan does not have to pay for an upper partial denture 
(D5213 and a lower partial denture (D5214) provided on April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Entresto.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device, by report (D7880). 
 
You asked the Plan to pre-approve the occlusal orthotic device, by report (D7880). You say that you would like 
to request something if not all the services recommended to you can be done. You also say that you are unable 
to pay in full for the services. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
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 
occlusal orthotic device, by report (D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim complete denture (maxillary) (D5810) and 
interim complete denture (mandibular) (D5811). 
 
 
You asked the Plan to pre-approve dental services. You say that you have no teeth, so you need the requested 
services. The Plan denied your request. The Plan says this service is not covered under your 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. Interim complete denture 
(maxillary) (D5810) and interim complete denture (mandibular) (D5811) are not covered under the Plans 
dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested interim complete denture 
(maxillary) (D5810) and interim complete denture (mandibular) (D5811) are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve interim complete denture 
(maxillary) (D5810) and interim complete denture (mandibular) (D5811).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary that the enrollee be 
transferred to a SNF. The Plan denied your request. The Plan says the enrollee has met the 100-day SNF stay 
benefit and is not eligible for a continuation of SNF benefits. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 13, 
2021, to February 07, 2022, (56 days) and March 10, 2022, to April 23, 2022 (44 days). The Plan has covered 
100 days of SNF care.  
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 22, 2022. 
 
You asked the Plan to pay for the refraction. You say that the refraction should be covered because you have a 
complicated medical history and changing doctors is extremely difficult. The Plan denied your request. The 
Plan says the service was not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on August 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mobile cardiac event monitor (MCOT) (93228) 
provided on December 16, 2021. 
 
You asked the Plan to pre-approve the MCOT. You say that this service was medically necessary for the 
enrollee. The Plan denied your request. The Plan says the MCOT is not medically necessary. 
 
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 MCOT. Our reviewer says that the 
requested MCOT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no supportive evidence that the ordering practitioner documented any standard, non-MCOT, ambulatory electrocardiogram (ECG) monitoring. Therefore, the reviewer found there is insufficient 
documentation to support the medical necessity for an MCOT monitor in this case. 
 
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 MCOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the mobile cardiac event monitor (MCOT) (93228) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee must receive care from a network 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 July 20, 2022, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the emergency room services. 
 
You asked the Plan to waive the cost share for the emergency room services. You say that you believe you 
should not be charged for these services as they were medically necessary. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $90 
copayment for emergency care services.  
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within the emergency care 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 cost share for the 
emergency room services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service [Enter date the requested 
item or service was exhausted]. Therefore, we decided that the Plan does not have to pay for the dental services 
on December 30, 2021.