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

 
We decided that the Plan does not have to pay for an outpatient visit provided on October 18, 2022. 
 
You asked the Plan to pay for an outpatient visit. You say that the records attached support the services 
provided. 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 outpatient visit 
provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, shoe inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are 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 pre-approve foot orthotics, shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 09, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was a routine eye exam and 
this service should be covered in full. 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 $35 
copayment for vision care. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the vision 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 an office visit provided on 
January 09, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injections. 
 
You asked the Plan to pre-approve Supartz injections. You say that the requested Supartz injections is 
medically necessary. The Plan denied your request. The Plan says the requested Supartz injections is not 
medically necessary. 
 
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 Supartz injections. Our reviewer says 
that the requested Supartz injections is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record does not document failure of 
a trial of conservative non-pharmacologic therapy or treatment with simple analgesics. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Supartz injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 24, 2022 
to July 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 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 subsequent nursing facility care provided on April 
24, 2022 to July 15, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 22, 2022. 
 
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 April 23, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 22, 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 
December 22, 2022, to December 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this was the result of a 
mistake, and you should not have to pay for it. 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 $290 
copayment per day for days 1-7 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says you then pay a $0 copayment per day for days 8-90. You have been asked to pay a $290 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $1,740 ($290 copayment per day x 5 days = $1,740). 
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 December 22, 
2022, to December 28, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network Botox injections provided 
from February 7, 2022, to August 18, 2022. 
 
You asked the Plan to waive the coinsurance for in-network Botox injections. You say that you were not 
charged this much last year and want this to be reviewed. 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 Medicare Part B prescription drugs. Based on the allowed amount of this Medicare Part B drug, 
you are being asked to pay the 20% coinsurance amount of $923.60 ($304.40 + $309.60 + $263.16 + $46.44 = 
$923.60). 
 
 
You have been asked to pay a $923.60 coinsurance for in-network Botox injections. This item/service falls 
within the Medicare Part B prescription drugs 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 in-network Botox injections provided from February 7, 2022, to August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
November 15, 2022, to November 18, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you were in the ER 
for two days before they gave you a room, which wasn't clean. You should not have to pay for this stay. 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 $290 
copayment per day, for days 1 through 7 for inpatient hospital care. You were hospitalized for 3 days, resulting 
in a $870 total copayment ($290 x 3 = $870). 
 
You have been asked to pay an $870 total copayment for an in-network inpatient stay.  This item/service falls within the inpatient hospital care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an in-network inpatient stay provided from November 15, 2022, to November 18, 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 
December 31, 2022, to January 5, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you reached your out-
of-pocket maximum amount prior to the stay. 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 $155 
copayment per day, for days 1 to 7 of inpatient hospital care.  You have been asked to pay a $155 copayment per day, for days 1 to 6 of your inpatient hospital stay. 
However, since you have reached your maximum out-of-pocket amount during your stay, you only owe 
$502.91. 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 December 31, 2022, to January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 04, 2023. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 04, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on December 31, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration for the services provided. 
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 x-rays provided on 
December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly base metal 
tooth #5 (D6241), and retainer crown - porcelain fused to predominantly base metal tooth #'s 4 and 6 (D6751). 
 You asked the Plan to pre-approve the dental codes represented by D6241 and D6751. You say that you never 
had a bridge and you were told the request was denied because you had a bridge less than 24 months ago. The 
Plan denied your request. The Plan says the requested dental services are not medically necessary. 
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 Plan covers the dental 
codes represented by D6241 and D6751 when the services are medically necessary and reasonable.  
 
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 the dental codes represented by D6241 
and D6751. Our reviewer says that the documentation provided does not meet criteria for coverage for a fixed 
bridge replacing missing tooth #4. Our physician reviewer found the appeal is for the denial of coverage for a 
fixed bridge replacing missing tooth #5 with a pontic (D6241) using teeth #'s 4 and 6 as abutment retainers 
(D6751). The reason for the denial was that the service does not meet the criteria for coverage. A fixed bridge 
may be covered to replace a single maxillary anterior tooth if no maxillary posterior teeth are missing. In this 
case tooth #4 is a posterior tooth and there are additional posterior maxillary teeth missing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental codes represented by D6241 and D6751 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain fused to predominantly 
base metal tooth #5 (D6241), and retainer crown - porcelain fused to predominantly base metal tooth #'s 4 and 
6 (D6751).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on 
October 18, 2022. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that the services should be 
covered. 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 targeted genomic 
sequence analysis panel provided on October 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric diagnostic evaluation with medical services 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve psychiatric diagnostic evaluation. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this is available in-network. 
 
 
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 
psychiatric diagnostic evaluation with medical services 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 pay for a filling (D2331) provided on December 14, 2022. 
 
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 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 filling (D2331) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the enrollee is being treated with continuous positive airway pressure (CPAP). The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured 
pressure support (AVAPS) capability and failure of such a device has not been documented. The Plan has 
indicated that coverage for such a device is available upon request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on December 14, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on December 14, 2022.