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

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367), 2D oral images (D0350), 
and an adjunctive pre-diagnostic test (D0431) provided by a participating provider on January 24, 2022. 
 
You asked the Plan to pay for a cone beam CT capture, 2D oral images, and an adjunctive pre-diagnostic test. 
You say that you went to an in-network provider. You say that you thought that these services would be 
covered. The Plan denied your request. The Plan says the rendered services have been correctly denied. 
 
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 cone beam CT capture (D0367), 2D oral images (D0350), and an adjunctive pre-diagnostic test (D0431) provided by 
a participating provider on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2) and therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the endosteal implants and therapeutic parenteral drug. You say that you 
would like to know why you have $3,000 in dental benefits if you cannot use it toward your dental work. The 
Plan denied your request. The Plan says these services are not covered under your benefit 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2) and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants provided by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that you need this done because you need the 
crowns. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 
dental implants provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular overdenture (D5866) and a 
maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a partial mandibular overdenture and maxillary partial denture. You say that 
you need these dentures because you cannot chew anything and have not taken your medicine because you 
need to take it with full meals. You also say that no one can fix your teeth and they cannot be repaired. The 
Plan denied your request. The Plan says partial mandibular overdenture is not covered under you benefit 
package. The Plan also says that the maxillary partial denture exceeds the maximum count allowed per period. 
 
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, partial mandibular overdenture 
(D5866) is not among those covered under this benefit. The contract says that maxillary partial denture 
(D5213) is limited to one procedure every five plan years. The record shows that you received this service on 
March 3, 2020 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a partial mandibular overdenture (D5866) and a maxillary partial denture 
(D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that the enrollee's current hearing aids are broken.
The appellant says that the enrollee is experiencing memory loss issues. The Plan denied your request. The
Plan says replacement hearing aids are not medically necessary for the enrollee's condition.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
replacement hearing aids only when there is a statement from the manufacturer that the existing hearing aid is
not repairable.
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 hearing aids. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the enrollee is an 80-year-old female
with a medical history that includes sensorineural hearing loss bilateral. This request is for a hearing aids
replacement as the current ones were reported to be no longer working and not able to be repaired. A recent
audiometry report was provided showing hearing loss. However, there was no provided statement from the
manufacturer that the aid is not repairable to meet criteria for consideration for replacement. Evidence of the
hearing aids being nonrepairable is needed.
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that
the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not
have to pre-approve hearing aids.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. Your rehabilitation needs can be safely met in an alternate and lower 
intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to medical appointments. The Plan denied your request. The Plan says you will have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 6), unspecified removable 
prosthodontic procedure (D5899 x 2), simple extractions (D7140 x 6) provided on February 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are shocked that some of the services were 
denied. You say that you are really frustrated. You say that you are on a very limited income. You also say that 
you cannot afford to pay for the denied services. The Plan denied your request. The Plan says the services 
denied correctly. 
 
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, there is an annual maximum benefit of 
$2,500. The record shows that the Plan paid $2,500 for the services you received on the date of service in this case. 
Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 6), 
unspecified removable prosthodontic procedure (D5899 x 2), simple extractions (D7140 x 6) provided on 
February 28, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no 
documented acute rehabilitation nursing needs. The rehabilitation needs can be safely met in an alternate and 
lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on December 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that you have followed the correct billing 
guidelines for payment. The Plan denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services provided on December 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for bioimpedance spectroscopy for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says medical necessity has not been established. Maximus overturned
the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bioimpedance
spectroscopy. The Maximus Physician Reviewer determined that bioimpedance spectroscopy for breast cancer
related lymphedema assessment to be beneficial. The Plan requested a reopen and argues that there is
insufficient evidence in the peer-reviewed medical literature to support the efficacy of bioimpedance devices
for the detection of lymphedema, and notes that there is no mention of bioimpedance spectroscopy in the
NCCN guidelines for the management of breast cancer associated lymphedema. The Plan is correct in this case.
The evidence in the medical literature and the clinical documentation in this case are insufficient to support that
bioimpedance spectroscopy is medically reasonable and necessary. Medicare coverage criteria are not met. 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 treatment have not been met. Therefore, we decided that the Plan does not
have to provide coverage for bioimpedance spectroscopy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 24, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 24, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 24, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of May 24, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond May 24, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 24, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 24, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on December 17, 2021. 
 
You asked the Plan to pay for the osseous surgery. You say that you feel this service should fall under 
periodontal maintenance at 50% coverage and a preventive service. You also say that this service is coded as 
surgery, but it is maintenance of your teeth. The Plan denied your request. The Plan says osseous surgery is not 
a covered benefit under your plan. The Plan also says that they confirmed with the dental office that you did 
have surgery on the date of service in question, not only maintenance work. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 
osseous surgery (D4261) provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation 
- established patient (D0120) provided September 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental cleaning and periodic oral exam. You say that when you called you 
were told twice that your bill would be paid. The Plan denied your request. The Plan says there is no coverage 
for services rendered by an OON provider. 
 
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 the dental 
cleaning and periodic oral exam when the services are provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the dental cleaning and periodic oral exam have not been met. Therefore, we decided that the Plan does not 
have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) 
provided September 7, 2021, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving misinformation from a plan representative after the services were 
rendered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We have decided that the Plan does not have to pay for the services provided from July 9, 2021, to July 11,
2021, and/or from July 16, 2021, to August 7, 2021.
You asked the Plan to pay for skilled nursing facility services for the enrollee. You say that these services were
medically necessary. The Plan denied your request.
The Plan says that based on the records provided, the Plan covered July 12, 2021, to July 15, 2021, but was
unable to cover July 09, 2021, to July 11, 2021, and July 16, 2021, to August 07, 2021 as the documentation
does not support any daily skilled services were required for those days. Maximus administratively overturned
the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required
medical records.
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.
Based on the medical records provided, the enrollees care was custodial in nature for much of the stay. No
daily skilled nursing services or daily skilled therapy services were either provided or required on the days in
question. The Plan has covered those days that showed care was provided that met the required criteria.
Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the
enrollee from July 9, 2021, to July 11, 2021, and/or from July 16, 2021, to August 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulator (TENS) and 
supplies, provided on January 7, 2022. 
 
You asked the Plan to pay for a TENS and supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of chronic low back pain (CLBP). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS and supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for a transcutaneous electrical nerve stimulator (TENS) and supplies, provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
two preventive procedures (D1999 x2), external bleaching (D9972), and resin-based composites (D2330 and 
D2331) provided from April 15, 2021, to May 13, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, preventive procedures, external 
bleaching, and resin-based composites. You say that the same services were covered during the 2020 plan year 
and you feel these services provided during the 2021 plan year should be covered. You also say that you were 
sent a letter in January 2022 saying you could go to any dentist and would be reimbursed. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), two preventive 
procedures (D1999 x2), external bleaching (D9972), and resin-based composites (D2330 and D2331) provided 
from April 15, 2021, to May 13, 2021 by a Medicare opt out provider.