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

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 7, 8, 9, and 10.

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says tooth #'s 7, 8, 9, 
and 10 do not meet the criteria for approval. The Plan also says that these teeth do not appear to have 
significant breakdown due to decay or trauma.

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 the crowns 
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 the crowns. Our reviewer says that the 
criteria for crowns on tooth #'s 7, 8, 9, and 10 do not meet the criteria and the crowns are not medically 
necessary. Our physician reviewer found there is worn lingual wear on tooth #7 by way of translucency seen as 
well as some radiolucency noted in the one provided x-ray. Overall, there is less than 50% of the incisal edge 
involved, and less than 40% of the total tooth structure missing or damaged. Tooth #'s 8, 9, and 10 show 
minimal structural damage with tooth #8 mesial showing a prior restoration and some facial bonding present on 
tooth #'s 8 and 9. Our reviewer found that tooth #10 does not clearly show any structural damage. The Plan 
requires that for anterior crowns to be approved that four or more surfaces be involved along with 50% or more 
of the incisal edge. In this case tooth #7 is the most involved however only about 20% of the incisal edge is 
compromised. Our physician reviewer also found that tooth #'s 8, 9, and 10 all have more limited damage, and 
more limited surfaces previously restored with no incisal edge damage seen.

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 the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #'s 7, 8, 9, and 10.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to waive the cost share charged for skilled nursing facility services.
You asked the Plan to waive this cost share. You say that you were charged for the discharge day in error. The
Plan denied your request. The Plan says you were not charged for the day of discharge. Maximus overturned
the Plans denial as there was information regarding the services charged missing from the case file. The Plan
requested a reopen and provided the required additional information.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan clearly says that you must pay a $160 copayment per day, for days 21-100 for SNF care.
The records provided by the Plan show that you were in a skilled nursing facility from January 18, 2021, to
February 8, 2021. The records show for days 1 to 20 (January 18, 2021, to February 6, 2021) were not charged.
The records show day 21 was February 7, 2021, and you were charged $160. The records show day 22 was
your discharge day, and you were not charged for this day.
Therefore, we decided that the Plan does not have to waive the $160 cost share charged for skilled nursing
facility services on February 7, 2021, and we have confirmed you were not charged for February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (coded 22566) provided to the enrollee on
December 3, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the primary procedure was identified as code 63302. Per the Medicare guidelines, the
multiple procedure reduction applies to code 22556 if a reduction has not already been taken. We 
overturned the Plans denial stating insufficient claim information was provided in the file. The Plan requested a
reopen and provided additional information. The Plan stated code 22566 is subject to multiple procedure
reduction when performed during the same session as another procedure. The Plan states that per the
documentation, code 63302 was the primary procedure.
Per Medicare guidelines, when multiple procedures, other than evaluation and management services, are
performed at the same session by the same provider, only the primary service is reimbursed at full value.
Subsequent procedures are reimbursed at a reduced rate. This accounts for the reduction in preservice and post
procedure services provided by the physician. The Medicare Fee Schedule Database value to determine
whether or not the procedure is subject to multiple procedure reductions. Code 22566 is subject to a multiple
procedure reduction (MPR) when performed during the same session as another procedure.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case code 22566
cannot be paid as billed due to the Medicare guidelines regarding multiple procedure reductions and the codes
relation to the primary procedure code reported. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for surgical services (coded 22566) provided to the
enrollee on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for the dialysis services
provided from May 3, 2021, to May 31, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was charged based on the claims submitted by the
providers and the Plan contract agreement. We overturned the Plans denial. The Plan requested a reopen
and stated that we did not apply the correct contract language and provided additional information.
The Plan says that you had dialysis services for 11 days. Based on the Plan contract you would be responsible
for 20% of the allowed amount for code 90999 which is $325. Twenty percent of $325 is $65 per service for 11
days.
The Plan is correct in this case. 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 cost share for each dialysis service provided. 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 or reduce the
cost share charged for the dialysis services provided from May 3, 2021, to May 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with codes A6549,
A6445 and A6545.
You asked the Plan to pre-approve the requested compression stockings. You say that these compression
stockings are medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the
Plans denial. The Plan requested a reopen and stated that we did not apply the correct coverage criteria.
The Plan states although you have ulcers, you have not had any surgical debridement or any type of
interventions/procedures for these to be considered as qualifying wounds to allow coverage for codes A6445
and A6545. In addition, gradient compression stockings coded as A6549 are non-covered under the surgical
dressing benefit.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that compression stockings
described by code A6549, A6445 and A6545 are either non-covered or have specific medical condition
coverage criteria.
Based on the Medicare guidelines, code A6549 is not covered and based on the medical records you do not
meet the criteria for codes A6445 and A6545.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with codes
A6549, A6445 and A6545.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 16, 2021.
You asked the Plan to pay for the lab services. You say that there is no contract which indicates the test is
included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of
the dialysis center.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on June 16, 2021.
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 member could have been treated in a different level of care such as skilled nursing.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for confusion. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network dental surgery (codes 41899 and
00170) for the enrollee.
You asked the Plan to provide coverage for dental surgical these services. You say that these dental services are
medically necessary for the enrollee. The Plan denied your request. The Plan says it was requested that these
services be covered under the enrollee's Medicare Part B medical benefit and not the enrollee's Plan dental
benefit. The Plan states these services are not covered under the medical benefit or the dental benefit. We 
overturned the Plans denial administratively because the Plans dental benefit rider was not included in the case
file. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. Medicare does not cover dental services. The Medicare rules sections lists the
limited circumstances when a dental related service would be covered under the Medicare Part B medical
benefit. The medical records state the enrollee had dental caries and cellulitis and abscess of the mouth on June
11, 2021. The enrollee complained of dental pain, broken down teeth to the gum line and constant infection due
to dental caries. The records state the enrollee has to have teeth extracted due to teeth broken off in the gum
causing pain and infection. Requesting inpatient procedure in a hospital setting needed due comorbidities.
Based on the medical records provided, the dental and health issues recorded do not meet the coverage criteria
for this service to be covered under the medical benefit. The Plan offers a dental benefit that exceeds Medicare
coverage. For that reason, the Plan's coverage rules apply in this case. Based on the medical records provided,
though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to provide coverage for out
of network dental surgery (codes 41899 and 00170) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Carboplatin, Gemcitabine and Pembrolizumab for the enrollee.
You asked the Plan to provide coverage for this drug treatment. You say that this drug treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Carboplatin, Gemcitabine and Pembrolizumab. Our Physician Reviewer determined that Carboplatin, Gemcitabine and Pembrolizumab are medically reasonable and necessary in this case. The Plan argues that there is no established evidence to support the use of pembrolizumab with carboplatin/gemcitabine for metastatic non-small cell lung cancer in any setting. The enrollee is a 79-year-old woman with metastatic adenocarcinoma of the right middle lobe of the lung, with the development of a left upper lobe lung mass. The enrollee's treatment regimen consists of Gencitabine and Carboplatin added to treatment with Pembrolizumab.
Our Medical Director has determined the Plan is correct in this case. While the addition of chemotherapy to pembrolizumab as first-line treatment has been shown to further improve the outcomes of patients with advanced NSCLC and a PD-L1 TPS of at least 50%, there is insufficient evidence to support that a regimen of Carboplatin, Gemcitabine and Pembrolizumab is medically reasonable and necessary for the enrollee 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 this drug treatment have not been met. Therefore, we decided that the Plan does not have to provide coverage for Carboplatin, Gemcitabine and Pembrolizumab for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance for the Botox injections provided on May 27, 2020, and December 2, 2020.
You asked the Plan to waive this coinsurance. You say that you did not believe the cost of each injection was correct. The Plan denied your request. The Plan stated that this cost share was charged based on the claim submitted by your provider and the Plan contract agreement. Maximus overturned the Plans denial stating the contract did not state specifically what you would pay for a Botox injection. The Plan requested a reopen and stated that Maximus did not interpret the Plan contract correctly in the case.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.
Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs, which would include an injection provided by a physician or physicians staff or outpatient facility. It is not possible for the Plan to list the name of each possible drug injection and the exact coinsurance that would be charged. The Plans contract gives an indication of the setting in which in the injection would be given and that there would be a 20% coinsurance, including a pharmacy drug if applicable. 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 20% coinsurance for the Botox injections provided on May 27, 2020, and December 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility
(IRF) to a skilled nursing facility (SNF).
You asked the Plan to provide coverage for this transfer. You say that this transfer was medically necessary.
The Plan denied your request. The Plan says there were no services offered at the SNF that were not being
provided at the IRF. We overturned the Plans denial stating SNF services would be beneficial. The Plan
requested a reopen and stated that we did not apply the correct coverage criteria. The Plan stated you
were already receiving the required care at the IRF facility which is a higher level of care than a SNF.
The Plan is correct in this case. 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. The
medical records show you were receiving all the services provided in a SNF as well as a higher level of care
that is provided in an IRF. There is no indication the SNF would have provided services that were not available
in the IRF. Medicare coverage criteria for this type of transfer were not met. Therefore, we decided that the
Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility (IRF) to a skilled
nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom motorized/power wheelchair base and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says overall, there is a lack of explanation for why the enrollee needs a custom wheelchair in place of the enrollee's current group 2 power wheelchair.
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 patient's 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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested accessories are not medically necessary as they appear to be more for convenience. A custom wheelchair is not required as she has a functional group 2 power wheelchair. Furthermore, the documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom motorized/power wheelchair base and accessories for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 6, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you met the MOOP amount for 
the year and should not be responsible for the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 the maximum-out-ofpocket (MOOP) amount for 2021 is $999. Your contract with the Plan also clearly says that you must pay a 
$120 copayment for emergency care. 

You received emergency care on July 6, 2021. The record shows that you had paid $1.16 toward the $999 
MOOP amount prior to receiving the services. Therefore, you are responsible to pay the $120 copayment. 

You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on July 
6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the deductible for surgery services, xrays
and physician services provided on September 30, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied to the deductible based on the services billed by
your provider and the Plan contract agreement. We overturned the Plans denial. The Plan requested a
reopen and stated that we did not apply the correct contract language. The Plan states that your provider
billed code 28400, which is an outpatient surgical code.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan says that there is deductible which applies to for 2020
and a cost share for each service once the deductible is met. Based on the claim submitted by your provider,
these services were billed appropriately for outpatient surgical services, x-rays and physician services. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is deductible and cost share for
these services. This cost sharing is a contractual obligation that had not been met at the time these services
were provided. Therefore, we decided that the Plan does not have to waive the cost share applied to the
deductible for surgery services, x-ray and physician services provided on September 30, 2020.