Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and electronic connection (E2311).
You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that these items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control power options through the joystick. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria. Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and electronic connection. Our Medical Director states that the clinical documentation does not support that an expandable controller, harness and electronic connection are medically necessary for you in this case to control power options through a joystick. Our physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, harness and electronic connection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and electronic connection (E2311).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the echocardiogram provided on 
September 24, 2022. 
 
You asked the Plan to reduce the coinsurance for the echocardiogram. You say that you were not informed of 
the 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 40% 
coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for the echocardiogram. This item/service falls within the out-of-
network 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. The total you owe is $98.08 ($245.19 
allowed amount x 40% = $98.08). Therefore, we decided that the Plan does not have to reduce the coinsurance 
for the echocardiogram provided on September 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 16, 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 the 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 the dental 
services on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 core 
buildup services (D2950) provided on January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the partial mastectomy provided on June 
08, 2022. 
 
You asked the Plan to waive the copayment for the partial mastectomy. You say that you did not received the 
surgery on June 8, 2022. 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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $295 copayment for the partial mastectomy. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 medical records show you 
received surgical services on June 8, 2022. Therefore, we decided that the Plan does not have to waive the 
copayment for the partial mastectomy provided on June 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 24, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told there is 
no copayment for inpatient hospital stays. 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 $295 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment for days 6-90 of the same inpatient hospital stay. You have been asked to pay a $295 copayment per day for days 1-2 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. You have been asked to pay a total of $590 ($295 copayment 
per day x 2 days = $590). 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 the inpatient hospital stay provided from January 24, 2023, to 
January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) provided on September 22, 2022.
You asked the Plan to pay for the bitewings. You say that you do not understand how your frequency was met prior. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and provided proof services 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 Plan's 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 17, 2022.
Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services, and a canalith repositioning 
procedure (CRP) provided on November 04, 2022. 
 
You asked the Plan to pay for physical therapy services, and a canalith repositioning procedure (CRP). You say 
that you were told that you did not need authorization for these 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 physical therapy 
services, and a canalith repositioning procedure (CRP) provided on November 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the benefit limitations. 
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 25, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy with removal of polyps provided on October 
27, 2022. 
 
You asked the Plan to pay for a colonoscopy with removal of polyps. You say that this is supported in the 
records. 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 colonoscopy with 
removal of polyps provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332) and 
resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on 
November 10, 2022. 
 
You asked the Plan to pay for dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your 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. Resin-based composite - three 
surfaces, anterior (D2332) and resin-based composite - four or more surfaces or involving incisal angle 
(anterior) (D2335) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2332 and D2335 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite - three surfaces, anterior (D2332) and resin-based composite - four or more surfaces or 
involving incisal angle (anterior) (D2335) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 30, 2023 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 31, 2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 30, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays and prophylaxis 
provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that your member guidebook does not state a time 
period for benefits. The Plan denied your request. The Plan says the claim was received after timely filing 
limitations. 
 
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 dental services was not filed until January 30, 2023. 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 the periodic oral evaluation, bitewing x-rays and prophylaxis 
provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-intravenous conscious sedation (D9248) provided on 
January 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 a non-
intravenous conscious sedation (D9248) provided on January 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on February 
08, 2023. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were unable to continue 
the surgery services. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for the cataract surgery. This item/service falls within the 
outpatient hospital 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. The medical records support the billed services. Therefore, we decided that the Plan does 
not have to reduce the copayment for the cataract surgery provided on February 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acute inpatient hospital care provided 
from August 13, 2022, through October 27, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not payable as you have not submitted proof of payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.    
Specifically, you have not submitted proof of payment to the Plan for these services. Therefore, we decided 
that the Plan does not have to issue reimbursement for the acute inpatient hospital care provided from  
August 13, 2022, through October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure and protective 
restoration (D1999, D2940) provided on January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 preventive procedure and protective restoration (D1999, D2940) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 23, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain 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 domiciliary or rest home 
visit provided on December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic (CGM) and supplies. You say that receiving the requested 
items will be beneficial to your health. The Plan denied your request. The Plan says you do not meet criteria. 
  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. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic (CGM) and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic CGM and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and hearing services provided on December 
02, 2022. 
 
You asked the Plan to pay for an office visit, and hearing services. You say that you did not know that you 
needed a new referral for these 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, and 
hearing services provided on December 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses (V2100, V2025) purchased 
on November 28, 2022. 
 
You asked the Plan to pay an additional amount for eyeglasses. You say that you want the Plan to pay an 
additional amount. The Plan denied your request. The Plan says you have exceeded the $150 allowance. 
 
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 up to a yearly allowance of $150. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay an 
additional amount for eyeglasses (V2100, V2025) purchased on November 28, 2022.