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

 
We decided that the Plan does not have to pay for prophylaxis (D1110), an interim partial upper denture 
(D5820), three (3) tooth extractions (D7210) and removal of four (4) residual tooth roots (D7250) provided on 
April 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for dental services. You say that you are requesting reimbursement as you had to get 
a loan in order to pay for your dental services. You also say you need the reimbursement as you still need 
additional treatment for your teeth. The Plan denied your request. The Plan says you received services from 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 Plan?s coverage rules apply in this case. The Plan covers dental 
services when the services are received by a participating network provider.  
 We looked at the file and Medicare rules. The EOC confirms that dental services must be rendered by a 
participating provider. Based on this information, we decided that the Plan's rules for coverage of dental 
services have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), 
an interim partial upper denture (D5820), three (3) tooth extractions (D7210) and removal of four (4) residual 
tooth roots (D7250) provided on April 8, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on May 5, 2021. 

You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support 
the code billed. The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye exam (99202) and an eye 
refraction (92015) provided on June 4, 2021. 
 
You asked the Plan to waive the deductible for a medical eye exam and an eye refraction. You say that a 
routine vision exam is covered every two calendar years and that your Plan covers the exam at 100% with no 
annual deductible when provided by an in-network provider. The Plan denied your request. The Plan says the 
cost share you are being charged 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 $600 
deductible for covered medical services.  The service at issue is subject to the Plan deductible of $600. The record shows that at the time this claim was 
processed, $175.83 of the $600 deductible had been met. The allowed amount of the claim is $86.83, resulting 
in a deductible obligation of $86.83. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $600 deductible for covered medical services. 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 deductible 
for a medical eye exam (99202) and an eye refraction (92015) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Total Right Knee Arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. 
 
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 this surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is being treated for tricompartmental osteoarthritis. She 
presented with right knee pain that is dull and aching. Height is 70 inches, weight 202 pounds, and body mass 
index of 29.09. Exam reveals mildly antalgic gait. There is right knee decreased range of motion with slight 
flexion contracture. There is pain at the joint line. Mild crepitation is noted with range of motion. X-rays are 
noted to show very large joint effusion with distention of the suprapatellar bursa; mild to moderate 
tricompartmental osteoarthrosis, most pronounced in the lateral compartment. However, detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures including formal physical therapy for the right knee. The requested surgery is not 
supported in peer-reviewed literature without well documented failure of all available conservative treatments 
prior to surgery. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for right total knee arthroplasty is not 
medically reasonable or necessary.  

 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Total Right Knee Arthroplasty for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered 
medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 
complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were admitted for left upper extremity cellulitis, bacteremia, and surgical management of infected AV 
graft. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is no documented need for an intensive, multi-disciplinary rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for the rental of a manual 
wheelchair from May 28, 2021, to July 28, 2021. 
 
You asked the Plan to waive this coinsurance. You say that this coinsurance along with other cost share applied 
for your medical issues is causing financial hardship. The Plan denied your request. The Plan says durable 
medical equipment requires cost share.  
 
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 durable medical equipment. 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 
charged for the rental of a manual wheelchair from May 28, 2021, to July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0602) 
provided on July 13, 2021. 
 
You asked the Plan to pay for the caries risk assessment and documentation. You say that you went to see the 
dentist that you were advised was in network. You say that when you got there, a different dentist saw you. 
You say that you were advised the whole office was in network. You also say that you received a bill. The Plan 
denied your request. The Plan says caries risk assessment and documentation is not listed as a covered service. 
 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 caries risk assessment and 
documentation is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the caries risk assessment and documentation (D0602) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration coded 96401 provided on 
May 5, 2021. 
 
You asked the Plan to pay for the chemotherapy administration. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
 We find that CPT code 96401 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee underwent a subcutaneous injection of Evinity for osteoporosis. There is a more appropriate 
code to be billed for the services rendered. Based on this information, we decided that Medicare rules for 
coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not 
have to pay for the chemotherapy administration coded 96401 provided on May 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from 
August 12, 2018, to September 10, 2018. 
 You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says Medicare coverage criteria were not 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 pay for these services. Our physician reviewer found there are no identifiable skilled 
nursing service needs and there are no identifiable skilled therapy service needs. The enrollee did not require 
skilled nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility services provided to the enrollee from August 12, 2018, to September 
10, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says that care can be rendered in an alternate setting, such as a skilled nursing facility. 
 
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. The plan has not substantiated their denial in this case. The plan has provided 
internal screenshots showing information that seems to be derived from medical records. However, the original 
medical records were not actually provided for review to Maximus. Therefore, we decided that the Plan has to 
pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee. 
  
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you had on March 24, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not think it is fair that the 
Plan only paid a small portion of this bill. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
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 $155 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $155 copayment for the CT scan. The CT scan falls within the radiological 
diagnostic 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 the computed 
tomography (CT) scan of the abdomen and pelvis you had on March 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90837) provided on June 24, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue 
were rendered in good faith. The Plan denied your request. The Plan says rules for out-of-network care have 
not been met. 
 
 
 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 
items/services 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 psychotherapy services (90837) provided on  
June 24, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on April 29, 2021. 
 
You asked the Plan to pay for CxBladder testing. You say that this testing provider actionable results. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (0013M) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray 
(D0220), additional periapical x-ray (D0230), root canal (D3330), and pulp vitality test (D0460) provided on 
June 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that the in network endodontist could not get you in 
for an appointment. You say that you had no choice but to go to the out of network dentist that was an hour 
away. You say that a plan representative advised the dental office that the service was covered 100%. You also 
say that you received a bill. The Plan denied your request. The Plan says the provider in this case is out of 
network. The Plan says that dental services received out of network are not covered. The Plan also says the 
pulp vitality test is not listed as a covered service. 
 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 dental services received out of 
network are not among those covered under this benefit. Additionally, pulp vitality test is not among those 
covered under the benefit, regardless of the provider's network status. Therefore, we decided that the Plan does 
not have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), additional periapical 
x-ray (D0230), root canal (D3330), and pulp vitality test (D0460) provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2021 by an out-
of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 laboratory services provided on July 13, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient eyelid surgery you had at an 
ambulatory surgery center on June 30, 2021. 
 
You asked the Plan to waive the deductible for the eyelid surgery. You say that this service should be covered 
because it was medically necessary and not cosmetic. The Plan denied your request. The Plan says this service 
was not denied.  Rather, you had not yet met your deductible at the time of the services, so you are responsible 
for the allowed amount for services until the deductible is met. 
 
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 a $300 deductible which applies to outpatient surgery.  
 
The eyelid procedure falls within the benefit category for outpatient surgery. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $300 deductible which applies to outpatient surgery. 
This cost sharing is a contractual obligation that had not been met at the time the eyelid surgery was received 
on June 30, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient 
eyelid surgery you had at an ambulatory surgery center on June 30, 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 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.