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

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), harness (E2313), and electronic connection device (E2311) for a power wheelchair for the enrollee.

You asked the Plan to provide coverage for power wheelchair accessories for the enrollee. You say that the requested accessories are medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct criteria. The Plan notes that E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 electronic accessory are requested to control power tilt and power leg lift through the joystick. The medical records do not show the enrollee needed to control these power options through the joystick. The medical records show the enrolled has 4+/5 right shoulder strength. The enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of the general power options.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Medicare does not provide coverage for equipment that exceeds the enrollees needs. Based on the medical records provided, the available clinical documentation does not support that the requested expandable controller, harness, and electronic connection were medically reasonable and necessary for the enrollee in this case. The notes do not show the medical necessity of controlling the power options through a joystick. Therefore, we decided that the Plan does not have to provide coverage for an expandable controller (E2377), harness (E2313), and electronic connection device (E2311) for a power wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on June 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist and assistants told you that your 
insurance was fully covering this procedure. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 6, 2023. The record 
also shows that the $2,000 annual maximum was used on dates of service February 8, 2023, in the amount of 
$920, March 7, 2023, in the amount of $920 and on June 6, 2023, in the amount of $160. Therefore, we 
decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of an 
intraocular lens prosthesis (66984), the anesthesia for procedures on the eye; lens surgery (00142), and the 
astigmatism correcting function intraocular lens (V2787) rendered by the out-of-network (OON) provider.  
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an 
out-of-network provider, without prior authorization.  
 
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 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 
items/services 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 the extracapsular cataract removal with insertion 
of an intraocular lens prosthesis (66984), the anesthesia for procedures on the eye; lens surgery (00142), and 
the astigmatism correcting function intraocular lens (V2787) rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing-four or more teeth per quadrant (D4341 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Parenteral Nutrition with an out-of-network (OON) 
provider at an in-network level of benefits. 
 
You asked the Plan to pre-approve the Parenteral Nutrition with an out-of-network (OON) provider at an in-
network level of benefits. You say that the services are medically necessary. The Plan denied your request. The 
Plan says there are in-network providers available to perform this service. 
 
Medicare rules say that plans can restrict members to a network of providers as long as medically necessary 
covered care is accessible and available through this network. 
 
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 
the Parenteral Nutrition with an out-of-network (OON) provider at an in-network level of benefits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from January 1, 2022, 
to January 31, 2022. 
 
You asked the Plan to pay for the physical therapy. You say that the original claim was submitted on time. The 
Plan denied your request. The Plan says the claim was processed correctly due to the claim not being filed until 
April 19, 2023, without good cause. 
 
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 physical therapy was not filed until April 19, 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 physical therapy services provided from January 1, 2022, to January 31, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services for date 
September 19, 2022, to September 30, 2022. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you refused the 
physical therapy 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 $40 
copayment for outpatient rehabilitation services.  
 
 
 
 You have been asked to pay the following amounts for physical therapy services:  
Dates of Service Total Charges Copayment 
September 19, 2022 $35.48 $35.48 
September 21, 2022 $28.35 $28.35 
September 22, 2022 $28.35 $28.35 
September 23, 2022 $28.35 $28.35 
September 26, 2022 $28.35 $28.35 
September 28, 2022 $32.89 $32.89 
September 30, 2022 $28.35 $28.35 
This item/service falls within the outpatient rehabilitation services benefit category. The amount you are being 
asked to pay is less than your contractual copayment because the allowed amount for these services is less than 
$40. 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 physical therapy services for date September 19, 2022, 
to September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical images, the periodontal maintenance, 
the intraoral periapical, the limited oral evaluation, and the surgical placement of endosteal implant provided 
from September 7, 2022, to November 7, 2022. 
  
You asked the Plan to pay for the dental services. You say that the Plan was unable to identify you on the 
attached claim from the information received. You say you are requesting to be reimbursed for these charges. 
The Plan denied your request. The Plan says your benefit for the requested items and 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 you were reimbursed $1,250 on July 7, 2023, which exhausted the benefit. Therefore, we decided that 
the Plan does not have to pay for the intraoral periapical images, the periodontal maintenance, the intraoral 
periapical, the limited oral evaluation, and the surgical placement of endosteal implant provided from 
September 7, 2022, to November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to regain maximum 
function. The Plan denied your request. The Plan says medical records do not support the need for an IRF 
admission and, the enrollee needs can be safely provided at another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that you are too old to undergo 
surgery and the injections help with the pain. The Plan denied your request. The Plan says this 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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. The review has 
determined that the requested genicular nerve block of the right knee is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that due to the enrollee's condition the 
VIA Disc procedure is medically appropriate. The Plan denied your request. The Plan says the VIA Disc 
procedure 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 the VIA Disc procedure. Our reviewer 
says that the VIA Disc procedure is not medically necessary. Our physician reviewer found that the VIA disc 
procedure is considered experimental therapy. Therefore, the request is not medically reasonable and 
necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided by a chiropractor on July 5, 
2023. 
 
You asked the Plan to pay for the office visit (99203). You say that you went in to get chiropractic services and 
the services should have been covered. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided by a chiropractor on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
June 27, 2023. 
 You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. Although the Plan offers coverage for OTC items, over-the-
counter COVID-19 test kits are excluded from this benefit. Therefore, we decided that the Plan does not have 
to pay for over-the-counter (OTC) COVID-19 test kits provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings and periodontal maintenance (D2331, D2391, 
D4910) provided on February 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 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 Plan's 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 fillings 
and periodontal maintenance (D2331, D2391, D4910) provided on February 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve the home health services. You say that your provider put in a request for 
you to receive in home care for your wound. You also say that you have been denied three times and feel you 
need help. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that you had complex wound status post initial hospitalization but does not meet 
technical requirements for home health nursing with face to face provider visit for plan of care. The records do 
not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve your condition, or to establish/perform a maintenance program to maintain your condition and 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the intraoral 
radiographic images (D0230) provided on July 17, 2023, and July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the office confirmed that they were in-network 
and you should not owe anything. The Plan denied your request. The Plan says your benefit for the requested 
items or 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 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 the Plan paid for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) on July 
17, 2023; therefore, your benefit for the requested items or services was exhausted on the date of service of 
July 17, 2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) 
and the intraoral radiographic images (D0230) provided on July 17, 2023, and July 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are weak and require a surgery that cannot be 
done until you complete rehabilitation. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.