Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan provided on 
March 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an MRI. You say that this should be covered. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-
of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a magnetic resonance imaging (MRI) scan 
provided on March 25, 2022, by an out-of-network (OON) provider.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 was admitted to a skilled nursing facility with pressure ulcers.  The 
record indicates that the enrollee has been receiving wound care. The record provided does not indicate the 
need for acute care services. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
 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 pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you need a 
minimum of seven additional rides to your appointments. You say you do not drive and are dependent on your 
elderly parents. The Plan denied your request. The Plan says additional transportation trips are not a covered 
benefit. 
 
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 additional non-emergency trips are not a coverage benefit. Therefore, we decided that the Plan does not 
have to pre-approve additional non-emergency transportation trips.
Appeal type: Surgery
Decision: Unfavorable


We decided that the Plan does not have to pay for surgical services (27860, 20902, 27827, 29515) provided on May 6, 2022.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed codes.

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 codes 27860, 20902, 27827 & 29515 are not supported in the medical record. Specifically, codes 27860, 20902, & 27827 are not supported in the operative report. Code 29515 is inclusive to the primary procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27860, 20902, 27827, 29515) provided on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller and accessories and
an E2300 power seat elevation system.

You asked the Plan to provide coverage for this equipment. You say that these accessories are medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

Our Medical Director looked at the case file and the reopen request. Medicare does not cover the E2300 power
seat elevation system under any circumstance. At issue is coverage for an expandable controller and
accessories. The Maximus Physician Reviewer the requested equipment was medically necessary.

The Plan requested a reopen and argues that, although there are three approved power options on this
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options
through the joystick. The medical records show you have a medical history that includes post-polio syndrome
and bilateral carpal tunnel syndrome recently treated surgically. You are independent with grooming and
hygiene, and independent with an assistive device for dressing, bathing, bowel and bladder management, meal
prep and feeding, and home management. Based on the records provided, the Plan is correct in this case.
The documentation does not support that the expandable controller (E2377), electronic connection (E2311),
and harness (E2313) were medically reasonable and necessary in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller and accessories have not been met. Therefore, we
decided that the Plan does not have to provide coverage for an expandable controller and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient hospital services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (code 0037U) provided on May 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the testing. You say that this laboratory service is not available in-network. The 
Plan denied your request. The Plan says services from out-of-network providers are not covered unless 
preauthorized. 
 
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 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 genetic testing (code 0037U) provided on May 
10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) 
provided on July 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your provider was OON. 
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 Plans 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 the dental cleaning (D1110) and periodic oral exam (D0120) provided on July 20, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and an extraction. You say that your doctor 
could not extract your tooth. You say that you were recommended here. The Plan denied your request. The 
Plan says services provided by an oral surgeon are not covered. 
 
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 a 
comprehensive oral evaluation and an extraction when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and an extraction have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an extraction (D7210) 
provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 1, 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 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 July 30, 2020. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory and/or service (V2797) provided on 
June 24, 2022. 
 
You asked the Plan to pay for vision supply, accessory and/or service (V2797). You say that you were told by a 
representative that these charges were covered by your insurance. The Plan denied your request. The Plan says 
vision supply, accessory and/or service (V2797) was denied because the services were not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. Vision supplies, accessories and/or services (V2797) are excluded from this benefit. 
 
We looked at the file and the Plan's rules. Vision supplies, accessories and/or services (V2797) are not covered 
by the Plan. Based on this information, we decided that the Plan's rules for coverage of vision supply, accessory 
and/or service (V2797) have not been met. Therefore, we decided that the Plan does not have to pay for vision 
supply, accessory and/or service (V2797) provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions (D7210 x) and the alveoloplasty (D7310 
x2) provided by an out-of-network provider on June 20, 2022. 
 
You asked the Plan to pre-approve the extractions (D7210 x8) and the alveoloplasty (D7310 x2), and the 
analgesia (D9230). You say that you were referred by an in-network provider to the out-of-network provider. 
You say you cannot afford the procedure. The Plan denied your request. The Plan says the covered services 
were reprocessed according to the in-network level 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 alveoloplasty (D7310 x2) is not 
among those covered under this benefit. The record shows your benefit for the extractions was exhausted on 
date of service June 20, 2022. Therefore, we decided that the Plan does not have to pre-approve the extractions 
(D7210 x4) and the alveoloplasty (D7310 x2) provided by an out-of-network provider on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 22, 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 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 July 29, 2020. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable prosthodontic (D5899) provided on July 19, 
2022. 
 
You asked the Plan to pay for the dental service. You say that your denture did not fit, and you needed this 
dental service done. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the removable prosthodontic is not covered by the 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 pay for the 
removable prosthodontic (D5899) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was not a standard visit. 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 June 23, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan of both jaws 
(D0367) and a bone replacement graft for ridge preservation (D7953) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you broke your tooth all the way up to your 
jawbone and needed the procedure to replace the tooth. You say the procedure was not cosmetic in nature and 
you cannot afford to pay for the services. The Plan denied your request. The Plan says codes D0367 and D7953 
are not included in the list of covered services, therefore the claim was processed correctly. 
 
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 computed tomography (CT) scan of both jaws (D0367) and a bone replacement graft for ridge 
preservation (D7953) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial denture (D5214)) provided on July 20, 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 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 3/01/2021. Therefore, we 
decided that the Plan does not have to pay for a partial denture (D5214)) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an intraoral - periapical first radiographic image tooth #19 (D0220) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that your benefit 
for the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for an intraoral - periapical first radiographic image 
tooth #19 (D0220) provided on July 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness upgrade, and electronic connection. 
 
You asked the Plan to pre-approve 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. Medicare rules say that an expandable controller is used to control 
multiple power options. The rules say that a power seat elevation system is not covered because it is not 
primarily medical in nature. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness is not needed to control 
the approved power switches. The power seat elevation system is not covered by Medicare. 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 pre-approve a power seat elevation system, expandable controller with 
harness upgrade, and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture 
provided on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider did not inform you that dentures 
are not a covered service. 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 pay for the 
maxillary partial denture and mandibular partial denture provided on July 5, 2022.