Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on October 
12, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this visit should be covered. 
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 $50 
copayment for each specialist visit.  
 
You have been asked to pay $50 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors 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 specialist office visit provided on October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is requested versus a lower 
level of care because the enrollee will require another two to four weeks of transitioning from the acute illness 
with discharge plan to a lower level of care as the enrollee continues to recover to their baseline level of 
function, or establish a new baseline. The Plan denied your request. The Plan says the LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. Our reviewer also found that the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 
May 3, 2022. 
 
You asked the Plan to pay for a crown. You say that this is a preventative service. You say that this should be 
covered. The Plan denied your request. The Plan says the rendered dental 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 a crown 
(D2740) provided by an out-of-network provider on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 19, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you have gone through the Plan's brochure, 
Annual Notice of Changes for 2022, and found nothing to support the Plan's decision. You also say that you 
would like a reversal of payment for this procedure. The Plan denied your request. The Plan says this service is 
not covered under your dental plan. 
 
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. The only type of extractions covered under your dental benefit are 
non-surgical extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction 
(D7210) provided on March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on February 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer SMART device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the patient is enrolled in a clinical trial of the device. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether implantation of this cardiac contractility modulation (CCM) system is medically 
necessary for treatment of congestive heart failure, which has been deemed refractory to optimal medical 
therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, 
with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Optimizer SMART device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on November 30, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you were never told that you had gingivitis 
irritation. You also say you were never told that additional procedures would be required/performed. The Plan 
denied your request. The Plan says this service is not covered. 
 
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 
gingival irrigation (D4921) provided on November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services on February 4, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the copayment of $45 you are being charged is correct 
since the amount due is under the normal $200 copayment 
 
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 $200 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services for 
ambulance services.  
 
You have been asked to pay $45 which is correct and it is less than the normal $200 copayment per one-way 
trip for emergency ambulance services and non-emergency ambulance services for ambulance services. 
Ambulance services fall within the ambulance services 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 ambulance services on February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computerized knee, advanced foot, duplicate 
alignable system, and second (duplicate) ankle (CPT code(s): L5617, L5828, L5845, L5848, L5856, L5984, 
L5981 and L5986). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered. The Plan states a request for a prosthetic knee and foot that 
meet the enrollee's needs and Medicare guidelines can be reviewed if submitted. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. Medicare guidance says that a 
prosthesis that meets, but does not exceed, the member's need can be provided. The second alignable system 
and ankle component exceeds your medical need. This cannot be covered. The code requested for the second 
ankle does not match the item requested. This cannot be covered. The records we have do not show why the 
requested computerized knee and advanced foot are needed. That is why these requested prosthetic parts are 
still denied. Therefore, we decided that the Plan does not have to pre-approve the computerized knee, advanced 
foot, duplicate alignable system, and second (duplicate) ankle (CPT code(s): L5617, L5828, L5845, L5848, 
L5856, L5984, L5981 and L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided March 
7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should process and pay reasonable 
medical claims. 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 October 14, 2020. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided March 7, 2022.  
 Your complaint about the Plans rules for coverage and feeling that the Plan is unqualified to make decisions 
about the frequency limits for procedures 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #19 (D2950) provided on January 12, 
2022, and a crown on tooth #19 (D2740) provided on January 31, 2022. 
 
You asked the Plan to pay for core build up and a crown. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says core build up (D2950) and a crown (D2740) are not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core build 
up on tooth #19 (D2950) provided on January 12, 2022, and a crown on tooth #19 (D2740) provided on 
January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator (E1392). 
 You asked the Plan to pre-approve portable oxygen concentrator. You say that you are oxygen dependent and 
received a denial for portable oxygen. You currently have equipment and received a letter stating that if the 
equipment was not covered you would be responsible for payment. The Plan denied your request. The Plan 
says the records do not provide the necessary documentation or medical necessity for oxygen. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a portable oxygen concentrator is not medically necessary.  This enrollee 
has a history of pulmonary embolism, but no other pulmonary diagnosis that would indicate a need for 
supplemental oxygen.  There is no documentation of hypoxemia.  Resting SpO2 breathing room air are 98% 
and 95%.  There are no testing results during exercise or sleep.  It is unclear whether or how long the enrollee 
has been on home oxygen, or whether she has a stationary concentrator.  The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided from March 4, 2021, 
to October 1, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that you must get these injections every 
few weeks and since its an experimental drug it should be covered. The Plan denied your request. The Plan 
says the coinsurance 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 20% 
coinsurance for each Medicare covered Part B drug. 
 
 
 
 
 
 You have been asked to pay $1,469.99 which is 20% of the allowed amount for injections.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
March 4, 2021 Injection $1,843.52 20% $368.70 
May 13, 2021 Injection $1,837.74 20% $367.55 
July 22, 2021 Injection $1,832.82 20% $366.56 
October 1 ,2021 Injection $1,835.88 20% $367.18 
Total:    $1,469.99 
 
Injections fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for injections provided from March 4, 2021, to October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five endosteal implants (D6010 x5). 
 
You asked the Plan to pre-approve the endosteal implants. You say that it is medically necessary for you to get 
these implants. The Plan denied your request. The Plan says this service is 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 five 
endosteal implants (D6010 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant provided by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that you know someone who had these services 
approved. The Plan denied your request. The Plan says the requested services are 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 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 pre-approve an 
endosteal implant provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not want to wait 36 months since the 
dental work was already scheduled by another dental office. 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 January 8, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on March 21, 2022. 
 
You asked the Plan to pay for debridement. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says full mouth debridement (D4355) is not covered by your supplemental 
dental benefits. 
 
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 full 
mouth debridement (D4355) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #11 (D2950), resin-based filling on 
tooth #2 (D2394), intraoral x-ray (D0220), and additional intraoral x-ray (D0230) provided on February 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 core build up on tooth #11 (D2950), resin-based filling on tooth #2 (D2394), intraoral x-ray (D0220), 
and additional intraoral x-ray (D0230) provided on February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test kit purchased on January 22, 2022.
You asked the Plan to pay for this test kit. You say that this test should be covered by the Plan. The Plan denied
your request. The Plan says on the date of purchase, over the counter home COVID-19 testing was not covered
by Medicare for reimbursement. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. At the time of purchase, Medicare did
not reimburse enrollees for over-the-counter screening tests of any type.
Therefore, we decided that the Plan does not have to pay for a home COVID-19 test kit purchased on January
22, 2022.