Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health care provided on August 01, 
2022, to August 31, 2022. 
 
You asked the Plan to pay for the inpatient mental health care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient mental 
health care provided on August 01, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for per admission for each inpatient stay 
provided on October 03, 2022, to October 20, 2022. 
 
You asked the Plan to waive the copayment for per admission for each inpatient stay. You say that you would 
like the copayment reviewed because you should not have been billed for two inpatient hospital stays. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for per admission for each inpatient stay. This item/service falls 
within the inpatient hospital 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 
per admission for each inpatient stay provided on October 03, 2022, to October 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care and discharge day management 
provided from September 15, 2021, through September 17, 2021. 
 
You asked the Plan to pay for subsequent hospital care and discharge day management. You say that the 
enrollee was not enrolled in hospice as they revoked the services. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. Original Medicare is also responsible 
for payment for services until the first day of the month after the hospice election has been revoked or 
terminated. 
 
The enrollee ended Medicare Hospice benefits on September 14, 2021. The services provided on September 
15, 2021, and September 16, 2021, were provided before the end of that month. The enrollee re-enrolled in 
hospice on September 17, 2021, which means the enrollee was under Medicare Hospice benefit for the service 
Provided on September 17, 2021. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care and discharge day management provided from September 15, 2021, through September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Ultrasound-guided breast cryoablation procedure (0581T, 
C261), provided on July 6, 2022. 
 
You asked the Plan to pay for an Ultrasound-guided breast cryoablation procedure. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
cryoablation in the setting of breast cancer have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an Ultrasound-guided breast cryoablation 
procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support the safety and efficacy of 
the requested service for the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Ultrasound-guided breast cryoablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for an Ultrasound-guided breast cryoablation 
procedure (0581T, C261), provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and periodontal scaling and root planing 
(D2750, D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for crowns has already been 
exhausted. Coverage for the periodontal scaling and root planing denied correctly as you do not meet the 
clinical requirements to be approved. 
 
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 August 30, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown and periodontal scaling and root 
planing (D2750, D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on December 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that the bitewings are allowed once a year and the 
denial should be a clerical error. 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 the Plan paid for a set of bitewings (D0272) on December 9, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 9, 2022. Therefore, we decided 
that the Plan does not have to pay for the bitewings (D0274) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic and a retainer crown provided on (D6245, D6740) 
provided on October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 annual dental benefit maximum 
allowance was met after the plan reprocessed the claim for the retainer crown (D6740) provided on October 13, 
2022. Coverage for the pontic (D6245) denied correctly as it does not fall within 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 Plan's 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 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a pontic and a retainer crown provided on (D6245, 
D6740) provided on October 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labyrinthotomy provided on October 11, 2022. 
 
You asked the Plan to pay for the labyrinthotomy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the labyrinthotomy 
provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre 3 sensor.
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that the requested item is more
comfortable, and that the Plan's denial reason does not make sense. The Plan denied your request. The Plan
says that rules for coverage for DME have not been met. Maximus overturned the Plan's denial. The Plan
requested a reopening based on Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that solely display results on a
smartphone and do not have a stand-alone receiver or integration into an insulin infusion pump do not meet the
definition of DME and will be denied as non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the FreeStyle Libre 3 sensor have not been met. Specifically, we found that the requested item is a
CGM that solely displays results on a smartphone and does not have a stand-alone receiver. Therefore, we
decided that the Plan does not have to pre-approve the FreeStyle Libre 3 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the heart ablation services provided on June 
17, 2022. 
 
You asked the Plan to waive the copayment for the heart ablation services. You say that you needed this 
service to keep your heart beating. The Plan denied your request. The Plan says this cost sharing was charged 
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 $300 
copayment for each in-network outpatient surgery.  
 
You have been asked to pay a $300 copayment for the heart ablation services. This item/service falls within the 
outpatient surgery 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 heart ablation 
services provided on June 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each out-of-network physical therapy (PT) 
service provided on June 15, 2022, to September 16, 2022. 
 
You asked the Plan to waive the coinsurance for each out-of-network physical therapy (PT) service. You say 
that you disagree with the 50% coinsurance for PT services. The Plan denied your request. The Plan says this 
cost sharing was charged 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 50% 
coinsurance for outpatient rehabilitation service. 
 
You have been asked to pay 50% coinsurance for each out-of-network physical therapy (PT) service. This 
item/service falls within the outpatient rehabilitation service 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 each out-of-network physical therapy (PT) service provided on June 15, 2022, to 
September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary to regain strength and 
be able to walk again and live independently. The Plan denied your request. The Plan says the requested IRF 
admission 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) x2 
provided on December 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like to be reimbursed because you were 
told you had to pay in full for services received. The Plan denied your request. The Plan says the services you 
received are covered 100% after a $25 copayment. 
 
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 resin-based composite - 
one surface, posterior (D2391) is covered with a $25 copayment under this benefit ($25 x 2 = $50). 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 pay for resin-based composite - one surface, posterior (D2391) x2 provided on 
December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan
denied your request. The Plan says that there was no documentation as to radiofrequency ablations (RFA) not
being appropriate for the member.
Our Medical director looked at the case file and the reopen request. At issue is coverage for facet joint
injections. Our Medical Director states that the case file does not contain documentation of why the enrollee is
not a candidate for radiofrequency ablation. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for facet joint injections. We looked at this physician's review, the file, and Medicare
rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not
been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections 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 you will receive the care needed in a rehab facility. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an 
inpatient rehabilitation facility. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the requested IRF admission 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 an IRF admission and services.
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 the enrollee and family are requesting 
services because they feel the requested facility has the best pulmonary management services. The Plan denied 
your request. The Plan says the enrollee can safely receive this care in another setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 they are 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.