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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), a partial 
upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve the 
dentures because you are allergic to metal. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the periodontal scaling and root planing, a partial upper 
denture with flexible base, and a partial lower denture with flexible base are 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 pre-approve 
periodontal scaling and root planing (D4341), a partial upper denture with flexible base (D5225), and a partial 
lower denture with flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #29. 
 
You asked the Plan to pre-approve the dental services. You say that you never had a crown done on tooth #29 
before. 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 13, 2018. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #29.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (procedure codes 97110, 97712, 
97116, 97530) provided to the enrollee on July 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 97110: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility 
 
 
 CPT 97112: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 
 
CPT 97116: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 
 
CPT 97530: 
 
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional 
performance), each 15 minutes 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the total time spent was 53 
minutes. However, these specific codes need to have the proper time documented per activity. The medical 
records do not state the time spent on the activities. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (procedure codes 97110, 97712, 97116, 97530) provided to the 
enrollee on July 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve psychotherapy visits. You say that the enrollee would benefit from the 
requested services. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 
psychotherapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the endodontic therapy, anterior tooth 
(D3310) provided on September 20, 2022. 
 
You asked the Plan to reduce the cost share for the dental services. You say that you were unable to see an in-
network provider because there are none in your area. 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 55% co-
insurance for each visit for covered endodontic services. Your contract with the Plan says that there is a $100 
deductible which applies to dental services. At the time this claim was processed, $0 of the $100 deductible had 
been met. You have been asked to pay the deductible and a 55% co-insurance for a total of $976.14. 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 reduce the cost share for 
the endodontic therapy, anterior tooth (D3310) provided on September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 13, 
2022, to July 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be covered. 
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 $250 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $250 copayment for inpatient hospital 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 inpatient 
hospital stay provided on July 13, 2022, to July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on April 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that this patient resides at a nursing home facility, and 
does not leave the facility for exams. You also say that you were unaware of the Plan this patient was enrolled 
with, and did not know to request a pre-authorization. The Plan denied your request. The Plan says services 
from non-participating providers are not covered unless pre-authorized. The Plan also says authorization was 
not obtained. 
 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 eye exam (92004) provided on April 5, 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 frames (V2020), bifocal lens (V2200), photochromatic 
tint (V2744), anti-reflective coating (V2750), and vision item or service (V2799) provided on August 10, 2022. 
 
You asked the Plan to pay for the frames, bifocal lens, photochromatic tint, anti-reflective coating, and vision 
item or service. You say that you are seeking a reimbursement, up to the allowable limit for new glasses which 
you needed because there were scratches on both lenses, and they were right in my field of vision. You also say 
that you are required to wear glasses when driving, and are looking for an exception to the standard 2-year 
policy. The Plan denied your request. The Plan says these services exceed the maximum benefit per period. 
 
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 these services once every 2 years. 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received glasses and frames 
on February 22, 2021, and your eyewear benefit has been exhausted. Based on this information, we decided 
that the Plan's rules for coverage of the frames, bifocal lens, photochromatic tint, anti-reflective coating, and 
vision item or service have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames (V2020), bifocal lens (V2200), photochromatic tint (V2744), anti-reflective coating (V2750), and vision 
item or service (V2799) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you are unhappy with the fit, size, and shape of 
your current dentures. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 items or services was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision of hyperplastic tissue (D7970). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs this dental procedure 
done for the proper denture placement. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because the excision of hyperplastic tissue 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 pre-approve the 
excision of hyperplastic tissue (D7970).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, you have not requested acupuncture treatments on the basis of chronic low back pain. Therefore, 
we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on May 29, 2022. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that you are requesting reconsideration for the 
denied claim. 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 outpatient clinic visit 
provided on May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to stay with the doctors that you 
have seen in the past because you have built a good rapport with them. The Plan denied your request. The Plan 
says you must receive your care from a network provider. 
 
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 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on February 23, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting reconsideration for 
the denied claim. 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 a nursing facility care 
visit provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additional reimbursement for the dental services provided on 
August 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only received one crown. 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 August 12, 2022, when 
the Plan covered $1500 in dental services. Therefore, we decided that the Plan does not have to pay additional 
reimbursement for dental services provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you think surgery needs to be done or 
you may lose usage of your hand. The Plan denied your request. The Plan says the service can be provided by 
an in-network provider. 
 
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 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you werent seen on this day so you 
shouldnt be charged. 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 $5 
copayment for Office visits. 
 
You have been asked to pay a $5 copayment for office visit. This item/service falls within the Office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for office visit provided on July 22, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for mental health visit provided on July 28, 
2022. 
 
You asked the Plan to waive the coinsurance for mental health visit. You say that you never had to pay this 
much in the past, so you dont know why its more now. 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 20% 
coinsurance for Outpatient mental health care. 
 
You have been asked to pay 20% coinsurance for mental health visit. This item/service falls within the 
Outpatient mental health 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 coinsurance for mental 
health visit provided on July 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical dental extractions (code 41899). 
 
You asked the Plan to pre-approve the dental services. You say that your physician said that it is medically 
necessary to get the surgical extractions done. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because surgical dental extractions are 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 pre-approve the 
surgical dental extractions (code 41899).