Persius/hicric huggingface dataset:
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 the services are necessary for the enrollee's health 
and ability to regain maximum function. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an inpatient rehabilitation facility and the enrollee's medical and 
therapy needs could be met in a skilled nursing unit. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership provided on April 15, 2022. 
 
You asked the Plan to pay for the health club membership. You say that if you had known the claim was going 
to be denied, you would have had an individual membership and would have paid with your own credit card. 
You say you should qualify for the Fitness Allowance. The Plan denied your request. The Plan says proof of 
payment did not have a name on the credit card statement to confirm you paid for the health club membership. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only you submit a Wellness Allowance reimbursement form along with proof of payment and any additional 
information outlined on the form.. 
 
The Plans rules for coverage of gym benefits have not been met because Specifically, you need to submit the 
required information to receive reimbursement. Therefore, we decided that the Plan does not have to pay for 
the health club membership provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
14, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. 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 $5 
copayment for Lab services. 
 
You have been asked to pay a $5 copayment for laboratory services. This item/service falls within the Lab 
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 laboratory services 
provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the dental services provided on 
March 1, 2022. 
 
You asked the Plan to increase the reimbursement for the dental services. You say that you were told you 
would be reimbursed $1,800 for dental services. The Plan denied your request. The Plan says your annual 
dental benefits have 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. 
 
The record shows your annual dental benefit has been exhausted. Therefore, we decided that the Plan does not 
have to increase the reimbursement for the dental services provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and endodontic 
therapy (D3310) provided on August 31, 2022, to September 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a limited oral evaluation (D0140) and 
endodontic therapy (D3310) provided on August 31, 2022, to September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that the patient informed you that she is covered under 
Medicare. You also say the provider is not responsible to request authorization for a Medicare patient to whom 
he renders services.. 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 August 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Evenity is medically reasonable or necessary or safe and effective for 
the 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve he Facial Reconstruction (Feminization) (15824, 21256, 
21139, 15773, 21209, 21122, 30410). 
 
You asked the Plan to pre-approve he Facial Reconstruction. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this procedure is cosmetic in nature and not medical. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Facial Reconstruction have not been met. Specifically, there is no functional impairment present in this member making this procedure cosmetic in nature. Therefore, we decided that the Plan does not 
have to pre-approve he Facial Reconstruction (Feminization) (15824, 21256, 21139, 15773, 21209, 21122, 
30410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on September 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should be covered for these services. 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 March 24, 2022, and 
June 27, 2022. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 26, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you had the procedure done and paid for before 
and would like it to be covered again. 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 periodontal maintenance (D4910) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a cleaning (D1110) provided on September 30, 2022. 
 
You asked the Plan to pay for the dental service. You say that the cleaning should be covered because the last 
one you paid for. 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. The last date the Plan paid for a cleaning was on January 25, 2022, which the enrollee would have 
coverage for the cleaning to be paid on or after July 25, 2022. Therefore, we decided that the Plan has to pay 
for a cleaning (D1110) provided on September 30, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upper partial resin-based denture (D5211) and an 
unspecified removable prosthodontic procedure (D5899) provided on February 14, 2022. 
 
You asked the Plan to pay for an upper partial resin-based denture and an unspecified removable prosthodontic 
procedure. You say that these dentures do not fit properly. The Plan denied your request. The Plan says the 
rendered dental services have been 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, D5899 is not among those covered 
under this benefit. The correct coinsurance has been applied to D5211. Therefore, we decided that the Plan does not have to pay for an upper partial resin-based denture (D5211) and an unspecified removable 
prosthodontic procedure (D5899) provided on February 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 05, 
2022, to July 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you shouldnt have to pay 
for this. 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 $385 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $385 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. You have been asked to pay $1,925 ($385 x 5 days) copayment for your inpatient stay. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on July 05, 2022, to July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a root canal (D3320) provided on July 13, 
2022. 
 
You asked the Plan to waive the coinsurance for the root canal.. You say that you now have discomfort in your 
tooth from the root canal and you feel you should not be responsible for the coinsurance. 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 20% 
coinsurance for a root canal.  
 
You have been asked to pay $136.60 which is 20% of the allowed amount for the root canal ($683.00 allowed 
amount x 20% coinsurance = $136.60). 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 coinsurance for a root canal (D3320) provided on July 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you received an invoice for $399 and you 
don't think it's fair because your normal ambulance copayment is $250. You also say that $399 is a bit 
expensive for 30 minutes of work. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service July 22, 
20222. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services 
rendered. The Plan denied your request. The Plan says the services were not appropriately 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. 
 
We find that inpatient CPT code 99222 was billed with an inpatient place of service code, 21. The enrollees 
claim information shows that the enrollee was receiving outpatient observation care at the time the evaluation 
and management services were provided.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99222 billed for date of 
service July 22, 20222.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care service provided on 
September 11, 2022. 
 
You asked the Plan to waive the copayment for emergency care service. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for emergency care service. This item/service falls within the 
Emergency 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 emergency care 
service provided on September 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99310 billed for date of service September 7, 
2021. 
 You asked the Plan to pay for the billed services. You say that the medical records demonstrate the need for 
services. The Plan denied your request. The Plan says there is a more appropriate code to describe the services 
provided. 
 
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 looked at the file and the rules. The claim shows that the services at issue were billed with an assisted 
living facility place of service code, 13. We find that CPT code 99310 is not supported. There is a more 
comprehensive code that describes evaluation and management services provided in an assisted living facility. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99310 billed for date of 
service September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an mammogram provided on September 
12, 2022. 
 
You asked the Plan to waive the copayment for an mammogram. You say that you are disputing the share cost. 
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 $85 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $85 copayment for an mammogram. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 mammogram provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test provided on September 24, 2022. 
 
You asked the Plan to waive the copayment for lab test. You say that you are disputing the share cost. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 lab test provided on September 24, 2022.