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

 
We decided that the Plan does not have to pay for ambulance services provided on February 1, 2021. 
 
You asked the Plan to pay for the ambulance services. You say to please review the documentation and 
reconsider your decision for reimbursement of this claim. The Plan denied your request. The Plan says the 
claim was not received within the allowed 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until July 11, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 February 9, 2022, and 
August 2, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on November 
4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on November 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on November 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray exams provided on January 26, 2022. 
 
You asked the Plan to pay for x-ray exams. You say that the enrollee is requesting reconsideration of the 
denied diagnostic testing. 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. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for x-ray exams provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction of tooth #1 (D7210) provided on 
October 20, 2022. 
 
You asked the Plan to pay for the extraction. You say that you had a simple extraction which is covered. The 
Plan denied your request. The Plan says that surgical extractions (D7210) 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. 
 
The Plan confirmed with the provider that a surgical extraction was performed. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested item or service is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for a surgical extraction of tooth #1 (D7210) 
provided on October 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on June 18, 2022. 
 
You asked the Plan to pay for a self-administered drug. You say that you were told the preparation kit 
purchased would be covered under Part B and you were not informed the kit was a separate charge from the 
procedure. The Plan denied your request. The Plan says the prescription drug is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a self-administered drug 
provided on June 18, 2022.  
 Benefits for a self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says that the enrollee the 
enrollee is not receiving full chemotherapy dose intensity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our physician reviewer found 
that the enrollee has stage three salivary duct carcinoma. Based on the regimen and the enrollee being greater 
than 65 with a neutropenic fever of greater than 20 percent, the requested use is FDA approved for the 
enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported 
or not recommended in any of the compendia. The documentation does support that the requested drug is safe 
and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility provided on October 05, 2022. 
 
You asked the Plan to pay for subsequent nursing facility. You say that the services does not require prior 
authorization. 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 subsequent nursing 
facility provided on October 05, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided from June 8, 2022, to June 10, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee had hospice until June 6, 2022 and all 
dates of service after June 6, 2022 need to be repaid. 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. Original Medicare is 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 June 6, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care provided from 
June 8, 2022, to June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
21, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you would like a refund, as 
the provider did not help you with your issue, and did not even examine you. 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on November 21, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no research showing that the enrollee's condition will respond better to this treatment. 
 
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 requested services. Our physician 
reviewer found that conventional three-dimensional conformal radiation therapy (3DCRT) may achieve 
acceptable normal tissue dose exposure and target coverage. Generally, an insufficient conventional 3D 
conformal plan warrants consideration for IMRT. While a plan comparison is provided, showing reduced small 
bowel and colon exposure with the IMRT plan, the 3D conformal plan does not exceed any accepted 
dosimetric constraints. The guidelines are explicit in that IMRT is covered in the treatment on 
infradiaphragmatic lymphoma only when a 3DCRT plan does not meet the acceptable normal tissue constraints 
using standard metrics. For this enrollee, the IMRT plan is modestly more homogeneous (i.e., less hot spots) 
than the well-designed 3D plan. While there is a plan comparison, there is no justification for the need of IMRT 
over 3D conformal radiation. Given the lack of justification of need, routine use of IMRT would not be 
furnished in accordance with accepted standards 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dental services (D0120 and D0210) on 
October 7, 2022. 
 
You asked the Plan to waive the copayment for dental services (D0120 and D0210). You say that you would 
like to request reconsideration for payment. 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 50% 
coinsurance after $100 deductible for dental services.  
 
You have been asked to pay a 50% coinsurance after $100 deductible for dental services (D0120 and D0210). 
This item/service falls within the dental 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 dental services (D0120 and D0210) on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network dental services on July 26, 
2022. 
 
You asked the Plan to waive the copayment for out-of-network dental services. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. Since the rendering provider is out-of-network the member was responsible for a higher cost than she 
would have been if the service was rendered in-network. 
 
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 50% 
cost share after the $100 deductible for out-of-network dental services.  
 
You have been asked to pay a 50% cost share after the $100 deductible for out-of-network dental services. This 
item/service falls within the dental 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 out-of-network dental services on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 18, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ophthalmic ultrasound (76514) provided on 
August 11, 2022. 
 
  You asked the Plan to pay for a diagnostic ophthalmic ultrasound (76514). You say that since this is part of the 
annual eye examination, it should not be billed to you. The Plan denied your request. The Plan says a review of 
the information determined that this visual field exam test (76514) is considered to be a separate diagnostic test 
that is not included in the annual vision exam. 
 
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. The Plan covers certain vision services as a supplemental (extra) benefit. A diagnostic ophthalmic 
ultrasound (76514) is excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers certain vision services as a 
supplemental (extra) benefit. This benefit includes one routine eye examination every calendar year. A 
diagnostic ophthalmic ultrasound (76514) is excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of a diagnostic ophthalmic ultrasound (76514) have not been met. Therefore, 
we decided that the Plan does not have to pay for a diagnostic ophthalmic ultrasound (76514) provided on 
August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost-sharing amounts applied to ophthalmological services 
provided on July 14, 2022. 
 
You asked the Plan to adjust the cost-sharing amounts applied to ophthalmological services. You say that you 
think the provider double billed and you should only have one copayment of $50. 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 in-
network copayment for each Medicare-covered specialist office or telehealth visit and you must pay $50 in-
network copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the 
eye.  
 
  You have been asked to pay $100 for ophthalmological services ($50 + $50 = $100). Ophthalmological 
services fall within the Physician/Practitioner services, including doctors office visits and Vision 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 adjust the cost-sharing amounts applied to ophthalmological services 
provided on July 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 11, 2022, to 
April 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the file 
shows that an invalid NOA with an admission date of June 10, 2021, was received on June 16, 2022. The 
subsequent claim was also reported with an invalid admission date. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from March 11, 2022, to April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain fused high noble crown on tooth #4 and #6 
(D4121) and the porcelain fused high noble pontic on tooth #5 (D6240) provided on March 30, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the porcelain fused high noble crown on tooth #4 and #6 (D4121) and the 
porcelain fused high noble pontic on tooth #5 (D6240). You say that the services were medically necessary, 
and that you have already paid for the work before you received the denial. The Plan denied your request. The 
Plan says there was no prior authorization submitted for the services. 
 
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 
porcelain fused high noble crown on tooth #4 and #6 (D4121) and the porcelain fused high noble pontic on 
tooth #5 (D6240). We found no exception that would require the Plan to pay for the porcelain fused high noble 
crown on tooth #4 and #6 (D4121) and the porcelain fused high noble pontic on tooth #5 (D6240). Therefore, 
we decided that the Plan does not have to pay for the porcelain fused high noble crown on tooth #4 and #6 
(D4121) and the porcelain fused high noble pontic on tooth #5 (D6240) provided on March 30, 2022, by an 
out-of-network (OON) provider.