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

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron tablets. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Specifically, the ondansetron in this case is being requested for post-operative nausea and 
vomiting. Therefore, we decided that the Plan does not have to pre-approve ondansetron tablets.  
 
Benefits for ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on July 6, 2023. 
 
You asked the Plan to pay for 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 pay for bitewing x-rays (D0274) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scleral contact lenses (V2531RT and V2531LT) provided 
on May 19, 2023. 
 
  
You asked the Plan to pay for the scleral contact lenses. You say that you have an ocular surface disorder and 
need specific contact lenses. You have tried glasses and traditional contact lenses, and nothing has worked. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the scleral contact lenses (V2531RT and V2531LT) provided on 
May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency trips. 
 You asked the Plan to pre-approve additional non-emergency trips. You say that you need transportation for 
dialysis treatments. The Plan denied your request. The Plan says the requested services were denied because of 
the limitation of the number of trips (transportation) covered by your health plan benefits. 
 
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 up to 32 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 trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection (27096).  
You asked the Plan to pre-approve an SI joint injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections can be covered when specific 
criteria are met. 
 
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 SI joint injection. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found the medical records do not 
document the degree and duration of pain relief from the previous saroiliac joint injection. Medical records are 
unclear if the enrollee was able to return to previous function or activities of daily living (ADL's). There is a 
requirement of 75% relief for the diagnostic SI injection and 50% consistent improvement in the ability to 
perform previously painful movements and activities of ADLs. Medical records do not document either. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of residual tooth roots (x6) (D7250), immediate 
denture - mandibular (D5140) and extraction (D7140) provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says you reached the 2 maximum for the removal of residual tooth roots any more are not 
covered and your $2,000 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the removal of residual tooth roots was exhausted on date of service April 6, 2023, as 
well as reaching your $2,000 annual maximum. Therefore, we decided that the Plan does not have to pay for 
removal of residual tooth roots (x6) (D7250), immediate denture - mandibular (D5140) and extraction (D7140) 
provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative (emergency) treatment of dental pain - minor 
procedure (D9110) provided on July 18, 2023. 
 
You asked the Plan to pay for palliative (emergency) treatment of dental pain. 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 palliative 
(emergency) treatment of dental pain - minor procedure (D9110) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage therapy. 
 
You asked the Plan to pre-approve a massage therapy. You say that you do not understand why a back injury 
such as a moderate compression fracture of T12 does not include massage therapy. The Plan denied your 
request. The Plan says the service in question is not covered under your contract under any normal 
circumstances. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve a massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that you do not agree with the $49 charge because it is a 
telehealth visit. 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 June 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you have been in a great deal of pain and 
needs these two extractions 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 on date of service February 7, 2023, and 
authorization 20232016030863. Therefore, we decided that the Plan does not have to pre-approve surgical 
extractions (D7210 x 2).
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee is limited by their weight-bearing status. The enrollees care needs can be 
met 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 pay for the dental services on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 July 13, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 13, 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 have not received the care or rehabilitation 
services that you need. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to a skilled nursing 
facility. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) provided on April 20, 2023. 
 
You asked the Plan to pay for dental implant services. You say that you were under the impression that your 
dental coverage benefits are $1,000 per year. The Plan denied your request. The Plan says the denied dental 
services are not covered 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. 
 
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 a custom 
fabricated abutment (D6057), and an abutment supported crown (D6058) provided on April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visits and the pulmonary 
diagnostic testing provided from February 17, 2023, to March 22, 2023. 
 
You asked the Plan to waive the cost share for the office visits and the pulmonary testing. You say that you 
should not be held responsible for these 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% 
coinsurance for each out-of-network Medicare-covered outpatient diagnostic procedure. Your contract with the 
Plan also clearly says that you must pay a $40 copay for each out-of-network Medicare-covered specialist visit. 
 
You have been asked to pay a $40 copayment for each office visit provided on February 17, 2023, and March 
22, 2023. These items/services fall within the physician/practitioner services, including doctors office visits 
benefit category. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
You have also been asked to pay 40% coinsurance for the pulmonary diagnostic testing. These items/services 
fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
 
Date of Service Items Allowed Amount 40% Coinsurance 
February 17, 2023 pulmonary diagnostic testing $31.45 $12.58 
March 9, 2023 pulmonary diagnostic testing $38.10 $15.24 
March 15, 2023 pulmonary diagnostic testing $181.45 $72.58 
 
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 office visits and the pulmonary diagnostic testing 
provided from February 17, 2023, to March 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve air ambulance services (A0430, A0435). 
   
You asked the Plan to pre-approve air ambulance services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request is not medically necessary because the records show the 
enrollee does not have a condition that requires immediate and rapid ambulance transportation. Available 
records indicate the enrollee's injury was in May, with the latest available records dated in early June 2023. The 
enrollee's current medical status was not included in this request. Further, the Plan covers ambulance care to the 
nearest appropriate facility. Records do not indicate that the enrollee has requested to go to the nearest 
appropriate facility to receive care. Finally, the Plan requires that care outside of the United States be paid for 
upfront with request for reimbursement after services have been rendered. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee suffered a traumatic 
brain injury while traveling abroad. The enrollee received emergency care. The enrollee and family are seeking 
to return to the United States (US). The requested flight is one of preference/convenience, not medical 
necessity, as required services appear to be available locally.  Furthermore, even if transport were medically 
necessary, the enrollee would have to go to the closest appropriate facility. In terms of a US facility, this would 
be somewhere on the east coast, not the west coast. As such, the requested air-medical transport from Portugal 
to Seattle, Washington is not medically necessary, reasonable or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve air ambulance services (A0430, A0435).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied for an office visit and injection provided
on September 12, 2022.

You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the
Plans denial. The Plan requested a reopen and noted that Maximus did not apply the correct criteria. The Plan
provided documentation to show the injection coded as J1030 is a valid code.

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 (such as copayments, deductibles, and coinsurance).

Your contract with the Plan clearly says that you must pay $10 copayment for each physician office visit and a
$20 copayment for each Medicare Part B drug, such as those administered by a physician. 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 applied for an office visit and injection provided on September 12, 2022.