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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 22, 2022.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you only received a dental evaluation on September 22, 2022. 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 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 July 22, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need these shoe inserts. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation mileage 
(A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation mileage. You say that you need 
the additional trip for an office visit. The Plan denied your request. The Plan says the requested transportation 
in each direction has exceeded the mileage limit. 
 
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. 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 non-emergency transportation mileage (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided from August 3, 2022, to August 16, 
2022.  
 
You asked the Plan to pay for foot orthotics. You say that this was medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pay for foot orthotics provided from August 3, 
2022, to August 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0429 and A0425 provided on February 1, 
2023. 
 
You asked the Plan to pay for procedure codes A0429 and A0425. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes J96.01 and R06.02 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure codes A0429 and A0425 provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown teeth #6, #7, #8, #9 (D6750). 
 
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 requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown teeth #6, #7, #8, #9 (D6750).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT angiography to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a CT angiography provided by an OON provider. You say that the test is 
necessary, and you do agree with the denial. The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a CT angiography to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental visit. You say that the requested out-of-network provider is the 
only dentist that makes you feel comfortable. The Plan denied your request. The Plan says dental services from 
an out-of-network provider are not covered by your supplemental benefits. Also, there are multiple in-network 
providers available within the enrollee's service area. 
 
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 are requesting 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 pre-approve a dental 
visit to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says the required Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. 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.
Whether or not IRF admission was beneficial for the enrollee was not of issue. The rules are clear that specific criteria must be met for coverage, as well as the expectation of an enrollee to be able to both participate in and benefit from an intensive rehabilitation program. The medical records provided with the appeal do not show the enrollee was of a physical condition that would allow active participation in an IRF therapy program. Based on the medical records, Medicare rules for coverage of IRF care were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
November 2, 2021, to November 19, 2021.
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the "through"
date.
The Plan must follow Medicare rules. Medicare rules say that the RAP contains the same date in both the
"from" and "through" date fields.
We looked at the file and Medicare rules. The RAP form submitted does not contain the same date in both the
"from" and "through" date fields. Based on this information, we find that the Medicare rules for payment of the
home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home
health services provided to the enrollee from November 2, 2021, to November 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room (code 99284) provided to the enrollee on October 11. 2021 under claim (Claim A).
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan demonstrated that the services billed on Claim A has already been paid. The documentation shows the enrollee was seen twice on the same date of service by two different providers.
The records show two separate services were performed or supported. The medical records confirm the enrollee was seen in the Emergency Department on at 4:27 am by the provider billing Claim A and then again at 11:08 pm on October 11, 2021, by a second provider. As the claim records provided show Claim A was previously paid, this was denied as a duplicate appeal. This appeal did not involve the visit at 11:08 pm by the other provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this issue was that the services billed under Claim A were shown to be previously paid by the Plan to the billing provider. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for emergency room (code 99284) provided to the enrollee on October 11. 2021 under claim  (Claim A).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6470) for tooth #27. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work 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 with the approval of D6740 for tooth #23 
and #24, and pontic (D6245) for tooth #25 and #26. Therefore, we decided that the Plan does not have to pre-
approve a retainer crown (D6470) for tooth #27.
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 the enrollee would benefit from a CGM. The Plan 
denied your request. The Plan says the 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. 
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 surgical placement of implant body: endosteal implant 
(D6010) and surgical access to an implant body (second stage implant surgery) (D6011) Tooth #19 and 20. 
 
You asked the Plan to pre-approve the dental services. You say that you are in need of 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. This benefit includes the 
requested surgical placement of implant body: endosteal implant and surgical access to an implant body 
(second stage implant surgery) but are limited up to two implants covered per year, or up to four implants 
covered per year for edentulous patients. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for surgical placement of implant body: endosteal implant (D6010) and 
surgical access to an implant body (second stage implant surgery) (D6011) Tooth #12 and 13 with an 
authorization date of January 21, 2023, to July 20, 2023. Therefore, we decided that the Plan does not have to 
pre-approve surgical placement of implant body: endosteal implant (D6010) and surgical access to an implant 
body (second stage implant surgery) (D6011) Tooth #19 and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9551). 
 
You asked the Plan to pre-approve the dental service. You say that the requested procedure is needed to prevent 
cracks and fractures. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the occlusal adjustment is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal adjustment (D9551).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthotics on December 29, 2022.  
 
You asked the Plan to waive the coinsurance for orthotics. You say that you were not aware there was a 20% 
coinsurance for this service, and you could not find this type of service mentioned in the Evidence of Coverage. 
You would like the plan to remove the cost share as you believe it is excessive. 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 each Medicare-covered durable medical equipment item. The provider billed in the amount of 
$1,500 and the allowed amount is $549.77. $549.77 x 20% = $109.95. Therefore, results in the total cost 
sharing amount of $109.95. 
 You have been asked to pay a 20% coinsurance for orthotics. 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for orthotics on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the anesthesia services provided on 
December 6, 2021. 
 
You asked the Plan to waive the cost share for the anesthesia services. You say that you just received the bill 
for services that were provided over a year ago. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to hospital services. Your contract with 
the Plan also says that the coinsurance is applied before and in addition to the deductible amount. Your contract 
with the Plan also says that there is 10% coinsurance for the hospital services. The annual deductible applies. 
 
You have been asked to pay $98.65 towards your deductible for the anesthesia services. The item or service 
you asked the Plan to waive the cost share for falls within the hospital services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to 
hospital services. This cost sharing is a contractual obligation that had not been met at the time the anesthesia 
service was received on December 6, 2021. 
 
You have also been asked to pay $10.96, which is 10% coinsurance of the allowed amount for the anesthesia 
services ($109.61 allowed amount x 10% = $10.96). You have been asked to pay a total of $109.61 ($98.65 
deductible + $10.96 coinsurance = $109.61). This item/service falls within the 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. Therefore, we 
decided that the Plan does not have to waive the cost share for the anesthesia services provided on December 6, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft replacement (D7953 ). 
 
You asked the Plan to pre-approve bone graft replacement. 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 bone 
graft replacement (D7953 ).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an additional emergency room visit rendered on October 30, 2022. 
 
You asked the Plan to pay for the additional visit. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says that the documentation does not support that the services 
were performed more than once on the billed date of service by the provider. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. We sent this case to a physician reviewer. Our 
reviewer found that the review has determined that the records did support that there was more than one 
emergency room visit on the same date. Based on this information, we decided that Medicare rules for 
coverage of the additional visit have been met. Therefore, we decided that the Plan has to pay for an additional 
emergency room visit rendered on October 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.