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

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
November 29, 2021. 
 
You asked the Plan to pay for dental services. You say that you feel like you are being discriminated against. 
The Plan denied your request. The Plan says services provided by out-of-network providers 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 Plan's coverage rules apply in this case. The Plan covers dental 
services when the services are provided out-of-network.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided on September 9, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the services provided are not covered benefits. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
contract language.
The Plan is correct in this case. 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, all services related to periodontics or
periodontal services are not covered.
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation
(D0180), periodontal maintenance (D4910), and complete series of intraoral x-rays (D0210) provided on
September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard-weight frame motorized/power wheelchair. 
 
You asked the Plan to pre-approve a standard-weight frame motorized/power wheelchair. 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 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 a standard-weight frame 
motorized/power wheelchair. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found in this case, there is not detailed documentation regarding the medical necessity for a power 
wheelchair in the home.  There is no detail regarding the enrollee's ability to do mobility-related activities of daily living in the home. 
 
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 standard-weight frame motorized/power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a standard-weight frame motorized/power 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the bitewing x-rays (D0274). We decided that the Plan does not have to 
pay for the panoramic x-ray (D0330).  
 
You asked the Plan to pay for the bitewing x-rays (D0274) and panoramic x-ray (D0330) provided on October 
28, 2021. You say that you do not feel that you should be responsible for these charges. The Plan says that no 
payment for the bitewing x-rays can be made because they are limited to one per calendar year. The Plan also 
says that the panoramic x-ray cannot be paid because full mouth x-rays are limited to once every 5 years. 
 
We decided that the Plan has to pay for the bitewing x-rays (D0274).  
 
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. The Plan did not provide proof showing that you had received bitewing x-rays 
prior to this October 28, 2021 date of service. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pay for the bitewing x-rays (D0274).  
 
We also decided that the Plan does not have to pay for the panoramic x-ray (D0330). 
 
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, full mouth x-rays are limited to once 
every 5 years. The record shows that you received a complete series of intraoral x-rays (D0210) on October 15, 
2021 and your full mouth x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pay for the panoramic x-ray (D0330). 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an 
interdisciplinary team approach to rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our physician reviewer found 
that you were admitted to the acute care hospital for shoulder replacement surgery. Your medical problems are 
stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While 
you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support a wound 
of such complexity that would require daily skilled nursing care or monitoring. In addition, internal medicine 
specifically states that your medical conditions are sufficiently stable. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Office Visit provided on September 30, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient 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 Outpatient Office Visit provided on September 30, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493 & 64494). 
 You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says the 
documentation did not show that the facet joint injection would be performed to determine if radiofrequency 
ablation would be beneficial.  
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that there is insufficient 
documentation to support diagnostic facet blocks. The physical exam does not quantify range of motion limits, 
facet loading tests, palpation tenderness. The request is considered 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493 & 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar decompression and fusion procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is a current daily smoker. 
 
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 requested services. Our physician 
reviewer found that smoking is a contraindication to elective spine fusion. There must be documentation of 
adequate smoking cessation, which is not present. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar decompression and fusion procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging (SPECT) 
test (78452) provided on December 22, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 a $275 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $275 copayment for the SPECT test. SPECT tests fall 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 myocardial perfusion imaging (SPECT) test (78452) provided on December 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on December 22, 2021, to 
December 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for physical therapy visits provided on December 22, 2021, to 
December 27, 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) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can receive the care she needs in another setting, such as at 
home, in a long-term care facility, or other 
outpatient setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct POS 
code. 
 
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 laboratory 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 laboratory services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care services provided on 
September 7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent Nursing Facility Care services. You say that you would like to 
request reconsideration for payment and the services provided were medically necessary. The Plan denied your 
request. The Plan says prior authorization is required for an out-of-network 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 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 Subsequent Nursing 
Facility Care services provided on September 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and electrical stimulation (97014) 
provided on December 15, 2021, through December 29, 2021. 
 
You asked the Plan to pay for the office visit and electrical stimulation. You say that you would like 
reconsideration because you have a chiropractic benefit and these services should be covered. The Plan denied 
your request. The Plan says coverage only includes manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) and electrical stimulation (97014) provided on 
December 15, 2021, through December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second filling (D2335) provided on January 14, 2021, 
intraoral x-ray (D0220) provided on August 18, 2021, and the fillings (D2331) provided on August 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not expecting to owe money for these 
services and were told at the time of services that insurance would cover the costs. You also say you have two 
insurance providers. The Plan denied your request. The Plan says you had two fillings provided in 2021 which 
were covered by the Plan. One was covered for date of service January 14, 2021, and the other was covered for 
March 4, 2021. Your benefit covers a maximum of two fillings per calendar year. Therefore, the remaining 
fillings you received in 2021 are denied as they exceed the frequency limitations of your benefit. In addition, 
intraoral x-rays are not a covered service. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, documentation supports that the 
requested items or services are not among those covered under this benefit or were requested in a frequency 
that exceeds what is covered by this benefit. Therefore, we decided that the Plan does not have to pay for the 
second filling (D2335) provided on January 14, 2021, intraoral x-ray (D0220) provided on August 18, 2021, 
and the fillings (D2331) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and implant 
supported crown (D6066) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says dental implants 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, the custom fabricated abutment and 
implant supported crown are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the custom fabricated abutment (D6057) and implant supported crown (D6066) 
provided on November 4, 2021.