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

 
We decided that the Plan does not have to pre-approve the implants (D6110 and D6111). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to receive 
these dental procedures. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because implants are not covered by the 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. 
 
  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 the 
implants (D6110 and D6111).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service May 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is needed to improve the 
enrollees strength. The Plan denied your request. The Plan says the remaining 10 physical therapy visits are 
not medically necessary, 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that additional visits are not medically necessary or reasonable based 
on the review of documentation by the physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and a powered pressure-reducing air mattress (E0277).

You asked the Plan to pre-approve a total electric hospital bed and mattress. You say that you have bed sores, you have nerve damage and are unable to move yourself from the waist down. The requested bed is necessary for repositioning. The Plan denied your request. The Plan says the requested bed is not covered by the Plan. The height adjustment feature is a convenience feature.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and a powered pressure-reducing air mattress (E0277).
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 this is medically necessary for the
enrollee. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been
met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no
additional services.

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 transfer to the LTACH is not medically necessary as the patient is not yet stable for
transfer and as it would not be clinically advantageous at this time. Completion of treatment at the current
facility is recommended.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft procedure for spinal surgery (20930). 
 
You asked the Plan to pre-approve an allograft procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 allograft procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that 
shows the requested allograft to be an effective and/or safe treatment for the enrollee's pathology. Further 
studies are needed to corroborate this allograft is as beneficial as, or more beneficial than, standard allografts. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
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 allograft procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft procedure for spinal surgery (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 11, 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 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 dental 
services on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a palliative (emergency) treatment of dental pain - minor 
procedure (D9110) provided on June 16, 2022. 
 
You asked the Plan to pay for a palliative (emergency) treatment of dental pain - minor procedure (D9110). 
The Plan denied your request. The Plan says the dental service provided was processed correctly. 
 
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.  
 
Therefore, we decided that the Plan does not have to pay for a palliative (emergency) treatment of dental pain - 
minor procedure (D9110) provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete denture. You say that you disagree with the denial of dental 
services. 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 November 9, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310) provided by a an 
out-of-network provider on July 11, 2022. 
 
You asked the Plan to pay for a diagnostic service consultation. You say that you would like the Plan to pay for 
these services. The Plan denied your request. The Plan says the rendered dental service is not a covered dental 
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 a 
diagnostic service consultation (D9310) provided by an out-of-network provider on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on May 5, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation - per site (D7953). You say that 
you need this intervention for your dental health. 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 pay for a bone 
replacement graft for ridge preservation - per site (D7953) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5226) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the charges. 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 March 29, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial denture (D5226)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5212).

You asked the Plan to pre-approve the dental services. You say that you lost your denture, and you need a replacement. 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 Plan's 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 date of service of June 23, 2022. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for bone marrow biopsies performed from 
April 7, 2022, to June 16, 2022. 
 
You asked the Plan to waive the copayment for the biopsies. You say that you thought you had met your out-
of-pocket maximum and you believe the Plan should waive the copayments. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. One claim was reprocessed due to meeting your out-of-
pocket maximum, but the other two remain upheld because you had not yet met the maximum amount. 
 
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 $6,700 
out-of-pocket maximum for in network services.  
 You have been asked to pay $1837.53 for the biopsies. This item/service falls within the outpatient hospital 
services benefit category. You had not yet met your out-of-pocket maximum at the time of service. 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 bone marrow biopsies performed from April 7, 2022, to June 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) 
 
You asked the Plan to pre-approve the crown. 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 the records do not 
indicate that the crowns would be appropriate for replacement and there is no decay. 
 
 
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 
crown (D2740)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment (D5862) for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for you to have this 
dental procedure done. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the precision attachment is not covered by the 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. 
 
  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 
precision attachment (D5862) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency situation. You say that 
you could not wait three months to see an in-network provider. 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 crown (D2740) provided by an out-of-network provider on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown tooth 
#'s 3, 4, 18, 19, 20, 30 (D6058), and custom fabricated abutment  includes placement tooth #'s 3, 4, 18, 19, 20, 
30 (D6057). 
 
You asked the Plan to pre-approve an abutment supported porcelain/ceramic crown tooth #'s 3, 4, 18, 19, 20, 30 
(D6058), and custom fabricated abutment  includes placement tooth #'s 3, 4, 18, 19, 20, 30 (D6057). The Plan 
denied your request. The Plan says these services are 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 
abutment supported porcelain/ceramic crown tooth #'s 3, 4, 18, 19, 20, 30 (D6058), and custom fabricated 
abutment  includes placement tooth #'s 3, 4, 18, 19, 20, 30 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for resin-based composite (D2335) provided 
on February 9, 2022. 
 
You asked the Plan to waive the coinsurance for the resin-based composite. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided, this cost-sharing is a contractual obligation that was agreed upon 
when signing up for the Plan and therefore, cannot be waived. 
 
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 waive the 
coinsurance for resin-based composite (D2335) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 pre-approve the 
dental services.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not require an intensive multidisciplinary approach to daily therapy. 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 issues in coverage for IRF admission. Our Medical Director states the documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee did not require at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for IRF care.
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 for the enrollee.
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. You say that the enrollee will benefit from IRF care and the 
enrollee's needs cannot be met at a lower level of care The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility (SNF). 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for a stroke. The record shows the enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation 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 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.