Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the complex needs of this member would be best managed in an LTACH level of care at this time. The Plan denied your request. The Plan says the enrollee's status is stable and improving. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.

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 the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you would like this service 
to be covered. The Plan denied your request. The Plan says this service is not covered under your 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 a 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the erupted tooth extraction (D7210), the bone graft (D7953), 
the general anesthesia (D9222), the collection and application of blood concentrate product (D7921), and the 
unspecified procedure (D9999) provided on September 14, 2021. 
 
You asked the Plan to pay for the erupted tooth extraction (D7210), the bone graft (D7953), the general 
anesthesia (D9222), the collection and application of blood concentrate product (D7921), and the unspecified 
procedure (D9999). You say that the Plan covers up to two extractions per year for an erupted tooth. You say 
the services should be covered. The Plan denied your request. The Plan says the services 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 
erupted tooth extraction (D7210), the bone graft (D7953), the general anesthesia (D9222), the collection and 
application of blood concentrate product (D7921), and the unspecified procedure (D9999) provided on 
September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture-maxillary (code D5110) and complete 
denture-mandibular (code D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you accidentally dropped your dentures on 
the concrete while cleaning them, and now you are without dentures and would like replacements covered. You 
say that the dentures were not repairable The Plan denied your request. The Plan says your benefit for the 
requested dentures 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 dentures was exhausted on date of service March 1, 2021. Therefore, we 
decided that the Plan does not have to pre-approve complete denture-maxillary (code D5110) and complete 
denture-mandibular (code D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on January 27, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus overturned the Plans denial for insufficient claim information. The Plan requested a reopen and provided additional information. The Plan demonstrated that a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 70450 and 70496. This PTP edit has a modifier indicator of 1. Per National Correct Coding Initiatives (NCCI), the PTP edit between these two code pairs has a modifier indicator of "1" which states modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed. Additionally, code 70496 has been paid by the Plan on March 01, 2022, with check number M0822087.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate coding guidelines. In this case, ode 70450 cannot be paid due to the omission of a required modifier. 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 pay for imaging services provided to the enrollee on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided in an outpatient hospital setting on November 1, 2021.
You asked the Plan to waive the copayment for these services. You say that the services should be covered as you disagree with the charges. 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 $350 copayment for Medicare-covered surgery or other services provided at an outpatient hospital setting. You have been asked to pay a $95 copayment for these services. This item/service falls within the Medicare-covered surgery or other services provided at an outpatient hospital setting benefit category.
The facility billed less than your applicable copayment of $350 for this service. This means that you have been asked to pay less than 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 eye exam provided in an outpatient hospital setting on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and a 
periapical x-ray (D0220) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that a coordination of benefits is needed from the commercial 
carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and a periapical x-ray (D0220) provided on April 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and bitewing x-rays (D0272) provided on July 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider's office told you that they were in-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0272) 
provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140) and an immediate mandibular denture 
(D5140) provided by an out-of-network provider on June 7, 2022, to June 22, 2022. 
 
You asked the Plan to pay for extractions and an immediate mandibular denture. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the rendered dental services 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 
extractions (D7140) and an immediate mandibular denture (D5140) provided by an out-of-network provider on 
June 7, 2022, to June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified oral surgery (D7999) provided on December 
1, 2021. 
 
You asked the Plan to pay for the unspecified oral surgery (D7999). You say that you are appealing the denied 
claim. The Plan denied your request. The Plan says the service 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 unspecified oral surgery (D7999) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified oral surgery (D7999) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty (D7320x4) provided by an out-of-network 
provider on January 28, 2022. 
 
You asked the Plan to pay for the alveoloplasty (D7320x4). You say that the provider is in-network. The Plan 
denied your request. The Plan says the service 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 the 
alveoloplasty (D7320x4) provided by an out-of-network provider on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
21, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider did not tell you that the service 
would not be covered because of the frequency. 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 comprehensive oral evaluation (D0150) was exhausted on date of service October 
15, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0350, D0150. D0210) provided on June 7, 
2022. 
 
You asked the Plan to pay for 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 the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 dental 
services (D0350, D0150. D0210) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265). 
The Plan denied your request. The Plan says this service is not covered by the Plan's 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, 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 
biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extractions (D7140, D7210) provided June 2, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you could only have 
two extractions. 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 the same date of service, June 2, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental extractions (D7140, D7210) provided 
June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Udenyca for the enrollee.
You asked the Plan to provide coverage for Udenyca. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Udenyca
(Pegfilgrastim-cbqv). The Maximus Physician Reviewer determined that the enrollee has had thrush and
gingivitis related to neutropenia. The use of growth factors such as with Udenyca is reasonable and medically
necessary. The Plan requested a reopen and argues that there is no established evidence to support the use of
long-acting pegfilgrastim for the treatment of a neutropenia-related infection. "For the enrollee's condition,
Udenyca (pegfilgrastim-cbqv) for the treatment of thrush and gingivitis related to neutropenia (neutropeniarelated
infection), do not have support in a Medicare-accepted compendia and Medicare-accepted medical
journals." The Plan is correct in this case. The documentation does not support that Udenyca was medically
reasonable and necessary for the enrollee in this case and was reasonably expected to be safe and effective.
Udenyca is FDA-approved as a leukocyte growth factor that is indicated to decrease the incidence of infection,
as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive
anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. The use of the drug in
the enrollee's clinical situation is not supported in the medical literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Udenyca for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that this is medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee has not had a 30-day on-
implanted heart monitor evaluation. 
 
The Plan follows Medicare rules. Medicare rules state that an implantable loop recorder may be covered under 
certain circumstances. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an implantable loop recorder. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for 
an implantable loop recorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (MCOT) with 
electrocardiographic recording device (93228) and technical support (93229). 
 
You asked the Plan to pre-approve an MCOT device. You say that the requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested 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 an MCOT device. Our reviewer says 
that the requested MCOT device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no supportive evidence that further, non-realtime, ambulatory 
electrocardiogram (ECG) monitoring would be inadequate for the enrollee's diagnosis. 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 an MCOT device have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (MCOT) with electrocardiographic recording 
device (93228) and technical support (93229).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on November 
15, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you should not be responsible 
to pay this. 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 35% 
coinsurance for out-of-network outpatient hospital surgery.  
 
You have been asked to pay $1,076.33 for outpatient surgery. This item/service falls within the outpatient 
hospital surgery 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 outpatient surgery 
provided on November 15, 2021.