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

 
We decided that the Plan does not have to pay for core buildups (D2950) provided on July 10, 2023, and 
August 10, 2023. 
 
You asked the Plan to pay for core buildups. 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 pay for core 
buildups (D2950) provided on July 10, 2023, and August 10, 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 the enrollee needs physical and occupational therapy 
as they are not able to use their left side. You say that the enrollee has had a recent fall which is why they are 
currently in the hospital. The Plan denied your request. The Plan says an IRF admission 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 the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the facility location is 56 miles away and it 
is not covered by the 50-mile policy of transportation. The Plan denied your request. The Plan says you are 
requesting an additional 6 miles for a total of 56 miles, and your benefit only allows 50 miles. The Plan also 
says that this request exceeds your benefit 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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910), and topical 
application of fluoride  excluding varnish (D1208) provided on June 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are supposed to receive an annual 
cleaning free of charge and the dental practice did not tell you that you would be responsible for the cost. You 
also say that you live on your retirement check only and you have no money to pay for extra expenses. The 
Plan denied your request. The Plan says your benefit for the requested services $2,000 dollar limit was met. 
 
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 services was exhausted on date of service June 7, 2023. Services were 
provided on May 10, 2023, with a claim total amount of  $1860.63 which was paid in full and applied towards 
your dental allowance leaving you $139.37 remaining ($2,000.00 - $1860.63 = $139.37). The services received 
on June 7, 2023 claim total was $261.62 and the remaining balance was applied leaving you liable for $122.25 
($261.62 - $139.37 = $122.25). Therefore, we decided that the Plan does not have to pay more for the 
periodontal maintenance (D4910), and topical application of fluoride  excluding varnish (D1208) provided on 
June 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox for Gastroparesis. 
 
You asked the Plan to pre-approve Botox. You say that manipulation of the pylorus with dilation and Botox 
injection is known to be a patient friendly, low-cost procedure with good patient outcomes. You also say that 
the technique provides your patients with superb relief with low morbidity and requires virtually no narcotic 
use or down time. The Plan denied your request. The Plan says the use of Botox for Gastroparesis is not an 
FDA approved indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Botox is not FDA-approved for the enrollees diagnosis. Our reviewer also found that its use is not supported 
by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox for Gastroparesis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on April 
7, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you called the ambulance 
due to your breathing and were treated but did not go to the hospital. The Plan denied your request. The Plan 
says without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on April 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are at a very high risk for falling. The Plan 
denied your request. The Plan says you no longer had SNF needs.   
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 
for services in an inpatient rehabilitation facility.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement; however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 
three visits weekly to regain or maintain their functional status. The enrollee can receive further services at a 
lower 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6740). 
 
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 (D6740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal instrumentation procedures on the spine. 
 
You asked the Plan to pre-approve spinal instrumentation procedures on the spine. You say that it is medically 
necessary. The Plan denied your request. The Plan says it 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 spinal instrumentation procedures on 
the spine. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process devices are experimental. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal instrumentation procedures on the spine have not been met. Therefore, 
we decided that the Plan does not have to pre-approve spinal instrumentation procedures on the spine.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 08, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were directed 
to return for your second rabies shot and advised you would not be charged another copayment. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 
emergency room (ER) visit provided on June 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable defibrillator. 
 
You asked the Plan to pre-approve implantable defibrillator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules state that implantable cardioverter defibrillators (ICDs) may 
be covered for certain indications. 
 
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 implantable defibrillator. Our reviewer 
says that the enrollee does not meet criteria for an implantable defibrillator. Our physician reviewer found the 
most recent ejection fraction was 62%. There is no documentation of a sustained ventricular tachyarrhythmia. 
Review of clinical documents does not show that the enrollee meets implant criteria for defibrillator insertion. 
In the absence of such documentation, implantation of an automatic defibrillator would not be considered 
medically necessary in the management of the enrollee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable defibrillator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable defibrillator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional physical and occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the physical and occupational therapy is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
because they have no medical need for continuation of a professionally supervised maintenance program.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee's motor strength and level of mobility has not 
significantly changed. The enrollee continues to have 4/5 motor strength in the lower extremities and is 
ambulating and performing transfers with an assistive device with modified independence. However, this does 
not require the skilled services of a physical therapist and the enrollee can continue to perform a home exercise 
program to improve their endurance. Therefore, the additional physical and occupational therapy visits are not 
medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional physical and occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the $1,087.24 cost share for multiple claims for services
provided July 27, 2022, and August 4, 2022.

You asked the Plan to waive this cost share. You stated that because you received the billing statement late, it
was out of sequence, so you should have no further copays for the year 2022. The Plan denied your request.
The Plan says this cost sharing was charged correctly. Maximus overturned the Plans denial for a lack of claim
information in the case file to show how your 2022 Maximum out of pocket was calculated. The Plan requested
a reopen and provided the required documentation.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a cost share for each
service that requires one until you reach your maximum out of pocket. The Plan has provided documentation to
show these claims were processed prior to you reaching your maximum out of pocket and therefore these
copayments require payment. 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 $1,087.24 cost share for multiple
claims for services provided July 27, 2022, and August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal surgery (D4277, D4265 and D4278) provided on
January 12, 2023.

You asked the Plan to pay for these dental services. The Plan denied your request. The Plan says your benefit
for the requested services was not available on the date of service in question. Maximus overturned the Plans
denial for a lack of claims in the case file to show these services were provided previously. The Plan requested
a reopen and provided the required claims.

The Plan is correct in this case. 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.
This service is only covered by the Plan every 36 months. The record shows your benefit for periodontic
services exhausted on dates of service April 7, 2022, and June 24, 2022 (less than 36 months prior to January
12, 2023). Therefore, we decided that the Plan does not have to pay for periodontal surgery (D4277, D4265 and
D4278) provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 10, 2022.

You asked the Plan to pay for these services. 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 demonstrated that
the DEX Diagnostic Exchange Registry, DEX Z-Code ZBBLD coverage status shows as "Not Covered".
Based on this guideline, the Plan has correctly denied the claim for payment as Z-Code
ZBBLD is not covered for the MoIDX program.

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 claim could not be paid as billed due to an error with the Z-Code
reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for genetic testing provided to the enrollee on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the seat lift provided on March 30, 2023. 
 
You asked the Plan to further pay for the services provided. You say that you were told you have 100% 
coverage. The Plan denied your request. The Plan says the chair is not covered. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
We looked at the file and Medicare rules. The file shows that you were reimbursed the allowed amount for the 
seat lift mechanism. The cost for the chair is not payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay for the 
seat lift provided on March 30, 2023.