Persius/hicric huggingface dataset:
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 a crown. You say that the enrollee had an existing DBLI composite on tooth 
#9 and the composite is leaking and breaking down. Replacing the existing composite is not an option. The 
enrollee needs a full crown. The Plan denied your request. The Plan says medical records do not show medical 
necessity. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable.  
 
 
 
 
 
 
 
 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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the tooth has an existing restoration which 
encompasses the much of the distal of the tooth right up to the incisal edge, however there is minimal depth to 
the restoration. In general, a crown is indicated on a tooth that has lost sufficient structure, usually in the order 
of 50% or more, such that the tooth cannot function without the additional strength of a crown. In this instance, 
the amount of total structure loss is about 20%, all on the distal aspect. There is direct access to restore the 
tooth as tooth #10 is missing which makes the restoration easier to place. Given the lack of extensive structural 
loss of tooth #9 by way of caries or fracture, there would no medical necessity to place a full coverage crown 
on the tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided on 
March 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the FoundationOne CDx (F1CDx) test. You say that this service was medically 
necessary and is covered by Medicare. The Plan denied your request. The Plan says this service was provided 
OON without prior authorization, and the enrollee was referred by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) 
provided on March 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME) (E12399) 
purchased March 3, 2022 
 
You asked the Plan to pay for the feed and flush enteral feeding pump. You say that you have been working 
with your current DME supplier for four weeks trying to secure a new pump. You request reversal of the denial 
and reimbursement for the 80% of the durable medical costs that you feel you are entitled to. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for miscellaneous durable medical 
equipment (DME) (E12399) purchased March 3, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not informed that out of network providers 
were only covered if an approved prior authorization was obtained in advance. The Plan denied your request. 
The Plan says there is no referring provider on the claim, so the Medicare Rule of Plan Directed Care does not 
apply. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on May 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 10, 2021, billed with 
codes 81238, 81220, 81226, 81226, 81230, 81227, 81355, 81241, 81291, 81240, 81306, 81328, 81335, 81231, 
81232, and 81283. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 10, 2021, billed with codes 81238, 81220, 81226, 81226, 81230, 81227, 81355, 81241, 81291, 81240, 
81306, 81328, 81335, 81231, 81232, and 81283.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric visit provided on October 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the requested service was a foreseen need, but not urgent or emergent care. 
The Plan also says that no prior authorization was made for the requested service. 
 
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 a psychiatric visit 
provided on October 18, 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 new patient outpatient office visit (99204) provided on 
April 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the claim determination on the 
basis that the services were medically necessary to this enrollee. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the new patient outpatient office visit (99204) 
provided on April 27, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954) 
provided by a participating provider on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. 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 maximum dental allowance amount of $1,000 on date of service April 8, 2022. Therefore, we 
decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954) 
provided by a participating provider on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on  
March 8, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are unhappy with the 
level of service provided and you feel the surgery was not medically required. You say that you were not 
informed prior to the surgery that a second doctor would be performing the surgery. The Plan denied your 
request. The Plan says the copayment applied is correct 
 
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 
copayment for an in-network specialist's office visit.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, including Doctor's Office Visits, 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 a specialist office visit provided on March 8, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation/inpatient hospital care provided on January 28, 
2022. 
 
You asked the Plan to pay for observation/inpatient hospital care. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for observation/inpatient hospital care provided on January 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you do not agree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says all genetic testing requires a prior authorization 
request. Additionally, all non-contracted providers require a prior authorization request as well. The Plan also 
says the tests performed are available in network. 
 
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 genetic testing provided on March 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic screening test provided on March 22, 
2022. 
 
You asked the Plan to pay for the molecular genetic screening test. You say that the enrollee's PSA was greater 
than 3 with a benign biopsy. You say that the enrollee is between 40 and 85 years of age. You say that the 
testing in dispute was medically necessary and appropriate. The Plan denied your request. The Plan says there 
was no documented result of prior prostate biopsy. The Plan says that there was no documented significant 
interval increase in PSA level. 
 
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 pay for the molecular genetic screening test. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation does not support that the result of the testing would directly 
impact the treatment being delivered to the enrollee. 
 
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 molecular genetic screening test have not been met. Therefore, we decided 
that the Plan does not have to pay for molecular genetic screening test provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the transition lenses purchased on April 21, 2022. 
 
You asked the Plan to pay for the transition lenses. You say that these transition lenses are medically necessary 
and should be covered. The Plan denied your request. The Plan says that the provider confirmed transition 
lenses were not medically necessary. 
 
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. In this case, the Plan has denied coverage by stating that the provider has 
confirmed transition lenses were not medically necessary. However, there is no proof of this correspondence 
anywhere in the case file. The provider, a provider contracted with the Plan, did not send medical records that 
indicate the transition lenses were not medically necessary. Without proof of this exchange, there is no 
evidence that the lenses were not medically necessary. Therefore, we decided that the Plan has to pay for the 
transition lenses purchased on April 21, 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 eyeglasses provided on March 27, 2022. 
 
You asked the Plan to pay for eyeglasses. You say that you understand that eyeglasses are covered only every 
two years. You say the service was a necessity as your vision had worsened since your last exam and you could 
not wait another year to have new lenses. The Plan denied your request. The Plan says you have exceeded the 
limits set in the subscribers agreement. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every two years. 
 
 We looked at the file and the Plan's rules. The file shows that you have exceeded the eyewear coverage limit. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on March 27, 2022.
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing needs or documented skilled therapy 
needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on March 17, 2022. 
 
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 6, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the imaging services have not been met. Therefore, 
we decided that the Plan does not have to pay for the imaging services provided on March 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, elastography; parenchyma (76981) provided 
April 11, 2022. 
 
You asked the Plan to pay for the ultrasound scan of organ tissue for measuring elasticity. You say that you 
would like this covered. The Plan denied your request. The Plan says payment cannot be provided until 
information about the primary payer is supplied. 
 
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 met its obligation with regards to coordination of benefits. Specifically, the Plan has requires information about benefits provided by your primary medical plan. As the secondary insurer, the Plan cannot 
be held responsible for the ultrasound scan of organ tissue for measuring elasticity until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ultrasound, 
elastography; parenchyma (76981) provided April 11, 2022.