Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided on January 01, 2022, to 
March 01, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you should only have to pay the $20 
copayment for the office visit. 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 Services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for dialysis. This item/service falls within the Services to treat 
kidney disease 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 dialysis provided on 
January 01, 2022, to March 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
March 11, 2022, to March 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not 
have to pay for the inpatient care due to a bad surgery. 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 $975 
copayment for inpatient hospital care. 
 
You have been asked to pay a $975 copayment for the inpatient hospital care. 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. The EOC says there is a $325 copayment per day for days 1-5 for inpatient care per 
benefit period. Your stay lasted 3 days from March 11, 2022, to March 14, 2022, for a total of $975. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
March 11, 2022, to March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been
met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. A representative from the enrollee's physician office confirmed the enrollee
is only using oral diabetes medications. The Plan also provided the enrollee's prescription drug claims that
confirmed the enrollee is not receiving insulin. Based on this information, we decided that Medicare rules for
coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to preapprove
a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need additional therapy. The Plan denied your 
request. The Plan says this is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the enrollee needs this. The Plan denied your request. 
The Plan says that the enrollee does not have adequate iron stores for this treatment. 
 
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 Retacrit. Our reviewer says that the 
requested drug, Retacrit, is medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of anemia of chronic kidney not on dialysis and has a hemoglobin of 7.5 mg/dl. The 
reviewer found that the Food and Drug Administration (FDA) has stated that Retacrit is indicated in patients 
for the treatment of anemia due to chronic kidney disease, including patients on dialysis and not on dialysis to 
decrease the need for red blood cell transfusion. Therefore, the reviewer found that the requested drug is 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
Retacrit.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you didnt receive any medical attention 
in the ER only went for lab work. 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 $120 
copayment for Emergency care. 
 
You have been asked to pay a $120 copayment for ER visit. 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 ER visit provided on May 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that your appeal request is supported by medical 
records. The Plan denied your request. The Plan says the enrollee must receive 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 pay for laboratory services 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 laboratory services provided on June 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal manipulative treatment (98943) provided on 
December 30, 2021. 
 
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 covered under the Plans 
contractual policy or by Medicare. 
 
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 does not meet Medicare criteria for coverage of chiropractic services 
and therefore, is not covered by the Plan. Therefore, we decided that the Plan does not have to pay for the 
extraspinal manipulative treatment (98943) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the surgical removal of 
residual tooth roots (D7250) provided by a participating provider on May 26, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 limited 
oral evaluation (D0140) and the surgical removal of residual tooth roots (D7250) provided by a participating 
provider on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320) provided by a participating 
provider on August 3, 2021. 
 
You asked the Plan to pay for endodontic therapy. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 
endodontic therapy (D3320) provided by a participating provider on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this evaluation was medically necessary. 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 6, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prothesis (L5987 and L5984) for the enrollee.
You asked the Plan to pre-approve this equipment. You say that this equipment should be covered by the Plan.
The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not follow the required criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an advanced foot
and ankle rotational unit prosthesis. The Maximus Physician Reviewer determined that the enrollee met the
criteria for a K3 advanced foot. Maximus overturned the denial. The Plan argues that the records do not support
that the enrollee's functional status is a K3 ambulator. The medical records show the enrollee is a 55-year-old
man who underwent a left transtibial amputation on September 22, 2020, because of infection. The Prosthetics
& Orthotics note from January 25, 2022, documents that the enrollee was then a Functional Level K3.
On March 16, 2022, the enrollee's provider documents a medical history that includes right heart failure,
hypertension, diabetes, weight gain, and sleep apnea. Exercise level was noted to be "None". The enrollee was
ambulating with an upright walker due to having COVID-19 about a month prior. The Plan is correct in this
case. The documentation in the case file does not sufficiently support that the enrollee's functional level was 3
or above.
A microprocessor-controlled ankle foot system is covered for beneficiaries whose functional level is 3 or
above, that is, having the ability to traverse most environmental barriers and may have a vocational,
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prothesis (L5987 and L5984) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service March 11, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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, we have confirmed that code 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87634 billed for date of service March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified dental procedure (D1999) provided on May 
24, 2022. 
 
You asked the Plan to pay for the unspecified dental procedure. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
unspecified dental procedure (D1999) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on May 
17, 2022. 
 
You asked the Plan to pay for an adjunctive test. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an adjunctive pre-diagnostic test (D0431) is not covered by your 
supplemental 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. 
 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 an 
adjunctive pre-diagnostic test (D0431) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for bitewings (D0274) provided by a participating provider on July 19, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you believe that the Plan should pay for this. 
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 bitewings (D0274) provided by a participating 
provider on July 19, 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 evaluation (D0180) and photographic images (D0350) 
provided on April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was an in-network 
provider and you would like the Plan to pay for the dental services. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because an evaluation and photographic images 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 pay for an 
evaluation (D0180) and photographic images (D0350) provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on March 10, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you have periodontal disease, and you 
need these services done. The Plan denied your request. The Plan says the enrollee does not have supplemental 
benefits. The rendered dental service is a supplemental benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
(D4910) provided by a participating provider on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging 
(D0220), bitewings (D0274), and prophylaxis (D1110), and a resin-based composite (D2392), provided by an 
out-of-network provider on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you were not covered. 
You say you have had this dentist for 10 years. 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 a comprehensive oral evaluation (D0150), intraoral imaging (D0220), bitewings (D0274), and 
prophylaxis (D1110), and a resin-based composite (D2392), provided by an out-of-network provider on April 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided a participating provider on 
June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 December 22, 2021. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating 
provider on June 8, 2022.