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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 2, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel the provider 
should take responsibility for your injury caused during a blood draw. You say that the hospital should waive 
the cost of the emergency room 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 a $90 
copayment for each emergency room visit.  
 
 You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency room visit 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 
emergency room visit provided on August 2, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network CPAP (continuous positive 
airway pressure) machine provided on July 05, 2023, to October 05, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network CPAP (continuous positive airway pressure) 
machine. You say that you have paid enough through this lease, please have this provider stop billing you. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an in-network CPAP (continuous positive airway pressure) 
machine. This item/service falls within the durable medical equipment (DME) and related 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 $162.11 ($53.15 x 3 = $162.11). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network CPAP (continuous positive airway pressure) machine provided on July 05, 2023, 
to October 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canal for tooth #14 (D3330), filling for teeth #4, 
#13 (D2392), a crown (D2740) and prefabricated post and core in addition to crown for tooth #14 (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 crown and prefabricated post and core was exhausted on date of service September 
1, 2023. The root canal was exhausted on September 5, 2023. Therefore, we decided that the Plan does not have to pre-approve root canal for tooth #14 (D3330), filling for teeth #4, #13 (D2392), a crown (D2740) and 
prefabricated post and core in addition to crown for tooth #14 (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization (D7922). 
 
You asked the Plan to pre-approve placement of intra-socket biological dressing to aid in hemostasis or clot 
stabilization. You say that the provider deems this as  The Plan denied your request. The Plan says this 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 pre-approve 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this is 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 March 23, 2022. 
Therefore, we decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your $3,500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pre-approve dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like approval for this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT (D0365). 
 
You asked the Plan to pre-approve cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 cone 
beam CT (D0365).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the resin-based composite - three surfaces, anterior 
(D2332), resin-based composite - two surfaces, posterior (D2392), and removal of residual tooth roots (cutting 
procedure) (D7250). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are a medical necessity. 
The Plan denied your request. The Plan says the benefit for the requested 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 the enrollees benefit for the resin-based composite - three surfaces, anterior and resin-based composite - 
two surfaces, posterior was exhausted on date of service September 25, 2023. The record also shows that the  
removal of residual tooth roots was exhausted on August 23, 2023. Therefore, we decided that the Plan does 
not have to pre-approve the resin-based composite - three surfaces, anterior (D2332), resin-based composite - 
two surfaces, posterior (D2392), and removal of residual tooth roots (cutting procedure) (D7250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete maxillary denture (indirect) (D5750) 
provided on June 19, 2023. 
 
You asked the Plan to pay for the reline complete maxillary denture. You say that you called the plan and were 
told that the reline would be covered. You also say that after you received the services rendered, they are being 
denied and had you been told the service was not covered you would have just done that yourself instead of 
receiving the services. The Plan denied your request. The Plan says services performed by a hygienist or 
denturist are not covered. 
 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 reline 
complete maxillary denture (indirect) (D5750) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service (D9310) and bone 
replacement graft (D7953) provided on July 14, 2023. 
 
You asked the Plan to pay for consultation and bone replacement graft. You say that this should be covered. 
The Plan denied your request. The Plan says these are not covered services. 
 
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 
consultation - diagnostic service (D9310) and bone replacement graft (D7953) provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 14, 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 March 17, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on July 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
 
 You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for mental 
health visits and other doctor appointments. The Plan denied your request. The Plan says the record shows you 
have already used 21 trips between February 2, 2023 to October 23, 2023 and the plan only allows 24 one-way 
trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for your mental health and doctor appointments. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing (D4341) provided 
on April 4, 2023. 
 
You asked the Plan to pay more 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 4, 2023. Therefore, 
we decided that the Plan does not have to pay more for periodontal scaling and root planing (D4341) provided 
on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office services provided on June 29, 2023. 
 
You asked the Plan to pay for outpatient office services. 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 outpatient office 
services provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA. 
 
You asked the Plan to pre-approve RFA. You say that you require the requested procedure due to experiencing 
intense pain and difficulty breathing. The Plan denied your request. The Plan says the requested procedure is 
not considered reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary.  
 
 We looked at the file and Medicare rules. Based on this information, specifically RFA for SIJ is not considered 
reasonable and necessary, we decided that Medicare rules for coverage of RFA have not been met. Therefore, 
we decided that the Plan does not have to pre-approve RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on July 14, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you have Part D coverage as part of your Plan and 
you have been invited to submit a Part D reimbursement request. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on July 
14, 2023.  
 
Benefits for immunization services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - resin with predominantly base metal tooth #29 
(D2721). 
 
You asked the Plan to pre-approve the crown. You say that you were not aware that the crown was recent. You 
also say that the crown was loose for the past year, recently broke off and you are having trouble eating without 
your tooth. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service September 26, 2022.  Therefore, we decided that the Plan does not have to pre-approve a crown - resin with predominantly base 
metal tooth #29 (D2721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy with facetectomy (63047).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no recent trial and failure of physical therapy for back pain. Also, the magnetic resonance 
imaging (MRI) does not show severe stenosis. 
 
  
 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar laminectomy with facetectomy (63047).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 dental services provided on February 8, 2023.