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

 
We decided that the Plan does not have to pre-approve a mandibular partial denture and diagnostic casts 
(D5214, D0470). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the partial dentures has 
already been exhausted. Coverage for the diagnostic cast (D0470) denied correctly as it does not fall within 
your dental 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture and diagnostic 
casts (D5214, D0470).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on November 28, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011 x2), semi-precision attachment  placement (D6192 x2), and semi-precision abutment 
 placement (D6191 x2). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial because it 
does not reach the maximum benefit 2023 coverage. You also say that it adds up to $2,980.00, leaving you a 
balance of $2,020.00 The Plan denied your request. The Plan says your benefit for the requested dental codes 
represented by D6011, D6192 and D6191 have 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 that the Plan approved the requested services up to your benefit limit at the time of the initial request. 
Therefore, we decided that the Plan does not have to pre-approve surgical access to an implant body (second 
stage implant surgery) (D6011 x2), semi-precision attachment  placement (D6192 x2), and semi-precision 
abutment  placement (D6191 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that the enrollee needs this device for 
medication purposes. You also say that the enrollee meets the criteria under this service. The Plan denied your 
request. The Plan says the enrollee does not meet the medical necessity criteria guidelines for coverage of a 
Freestyle Libre CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, and the enrollee does not require frequent self-adjustment of insulin dosage 
based on the blood glucose testing results. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 11, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on May 25, 2021.
You asked the Plan to pay for the physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the member was in hospice care and the provider needs to bill Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 22, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary visits provided on September 13, 2022, to 
September 20, 2022. 
 
You asked the Plan to pay for domiciliary visits. You say that the enrollee has had many life changes and is 
having difficulty keeping up. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary visits 
provided on September 13, 2022, to September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 00731, 99100, 71045, 99284 and 99222.
You asked the Plan to pay this claim. The Plan says while a portion of this claim was paid, Medicare billing criteria were not met for the denied codes. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided documentation showing that codes 99232, 99233, and 99238 were previously paid by the Plan.
The Plan follows Medicare rules. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. We find that codes 00731, 99100, 71045, 99284 and 99222 could not be paid as billed as they were either duplicate billings, contained status indicator errors and/or modifier errors. Medicare billing criteria for these codes have not been met. Therefore, we decided that the Plan does not have to pay for codes 00731, 99100, 71045, 99284 and 99222. provided to the enrollee from December 17, 2021, through December 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 28, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were advised there would be 
no copayment. 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 $50 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service except services 
provided at an independent clinical laboratory and in an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an ultrasound. This item/service 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 the ultrasound provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refill and maintenance of an implantable pump and a 
baclofen injection. provided on August 19, 2022. 
 
You asked the Plan to pay for refill and maintenance of an implantable pump and a baclofen injection.. You say 
that prior authorization was not obtained because you were unaware of a recent insurance change. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for refill and maintenance 
of an implantable pump and a baclofen injection. provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you have a history with this provider and 
would like to see them again. The Plan denied your request. The Plan says network providers are available to 
render necessary 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for external electrocardiographic (ECG) 
recording provided on November 01, 2022. 
 
You asked the Plan to waive the copayment for external electrocardiographic (ECG) recording. You say that 
you were not aware that there was a copayment for this service. 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 $75 
copayment for in-network diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $75 copayment for external electrocardiographic (ECG) recording. This 
item/service falls within the in-network diagnostic procedures and tests, including ultrasounds, at all locations 
of service 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 external 
electrocardiographic (ECG) recording provided on November 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
from October 15, 2022, to October 16, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you do not agree 
with paying for this service. 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 $150 
copayment for Medicare-covered outpatient hospital observation. 
 
You have been asked to pay a $150 copayment for the hospital observation services. This item/service 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 the hospital observation services provided from October 15, 2022, to October 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrophsiology provided on June 10, 2022. 
 
You asked the Plan to pay for electrophsiology. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for electrophsiology 
provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for D0180 (comprehensive periodontal evaluation - new or 
established patient) provided on December 6, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 D0180 
(comprehensive periodontal evaluation - new or established patient) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional pontic and retainer crown (D6750, 
D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial and are medically necessary. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted with the approved authorization for 3 pontics 
(D6240) and 1 retainer crown (D6750). 
 
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 will be exhausted with the plans authorization from 
January 21, 2023, to July 20, 2023. Therefore, we decided that the Plan does not have to pre-approve the 
additional pontic and retainer crown (D6750, D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says under limited circumstances, the plan will allow members to see out-of-
network providers for Medicare-covered services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
foot orthotics to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 22, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not agree with the copayment 
applied to this service. 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 $10 
copayment for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT). 
 
You have been asked to pay a $10 copayment for lab services. This item/service falls within the other 
Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT) 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 lab services provided on September 26, 2022.