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

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on July 
27, 2022. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that the records show the denial was 
erroneous. You also say that you would like the incorrect denial to be reversed, and proper payment to be 
issued. The Plan denied your request. The Plan says this service is not covered under the enrollee's contract 
under any normal circumstances. 
 
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 the fixed 
partial denture sectioning (D9120) provided on July 27, 2022.
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 have a problem with your veins blowing and 
need assistance from a nurse. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and you can receive the care you need at a lower level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 15, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are reducing the 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 October 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330), and gingival irrigation  
per quadrant (D4921) provided on December 13, 2022. 
 
You asked the Plan to pay for the oral hygiene instructions and gingival irrigation  per quadrant. You say that 
you have an optional dental rider and you were surprised when you received a denial letter. You also say that 
the dental office checks prior to the procedures that it is approved by insurance prior to treatment. The Plan 
denied your request. The Plan says although you are enrolled in the optional dental rider, if a service is not 
covered, we will not pay for that 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 oral 
hygiene instructions (D1330), and gingival irrigation  per quadrant (D4921) provided on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home laboratory testing provided on February 10, 
2023. 
 
You asked the Plan to pay for nursing home laboratory testing. You say that this was medically necessary and 
should be covered. We depend on the facility to get this authorization. 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 nursing home laboratory 
testing provided on February 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
August 13, 2021. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that they did not 
moniter you the entire ride, and should not get any more of your money. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network ambulance ride provided on August 13, 2021. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to predominantly base metal 
(D2751) provided on January 24, 2023, and February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking for assistance to cover dental 
services received from an out-of-network provider. 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 crown - porcelain fused to predominantly base 
metal (D2751) provided on January 24, 2023, and February 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 the enrollee has made progress but still is unsteady 
and gets tired after doing moderate activities. You say that the enrollee can benefit from more physical, 
occupational, and speech therapy. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility 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 the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown 
(D2954), endodontic therapy, anterior tooth (excluding final restoration) (D3310), complete denture - maxillary 
(D5110), and mandibular partial denture  resin base (including, retentive/clasping materials, rests, and teeth)  
(D5212). 
 
You asked the Plan to pre-approve the dental services represented by codes D2954, D3310, D5110 and D5212. 
You say that you are asking Medicare payments to be reduced as an act of much needed help since copayments 
make it very difficult to make ends meet. 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 services was exhausted on the pre-determination, $837, and $163 total 
paid for date of service February 24, 2023 ($837 + $163 = $1,000.00). Therefore, we decided that the Plan does 
not have to pre-approve a prefabricated post and core in addition to crown (D2954), endodontic therapy, 
anterior tooth (excluding final restoration) (D3310), complete denture - maxillary (D5110), and mandibular 
partial denture  resin base (including, retentive/clasping materials, rests, and teeth)  (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214), retainer crown 
(D6750) and pontic (D6240). 
 
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 mandibular partial denture (D5214), retainer crown (D6750) and pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eye exam (92002) provided on October 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the eye exam. You say that you asked the clinic if they accepted your 
insurance, and were advised that they did. The Plan denied your request. The Plan says you received this 
service from an OON provider, and you are responsible for the coinsurance amount that applied. The Plan also 
says that you were not provided with misinformation during your call with the Plan on October 17, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a 45% 
coinsurance for the diagnosis and treatment of diseases and injuries of the eye rendered by an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to pay more for the eye exam (92002) provided on October 
21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you received compression 
stockings in 2019 and they were covered. You also say that you are aware that you have to have an active ulcer 
in order to get them and you do. The Plan denied your request. The Plan says you do not have a qualifying 
wound for coverage of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220), each additional radiographic image (D0230), periodontal 
maintenance (D4910), and periodic oral evaluation - established patient (D0120) provided on September 15, 
2022. 
 
You asked the Plan to pay for the dental services. 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 bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image 
(D0220), each additional radiographic image (D0230), periodontal maintenance (D4910), and periodic oral 
evaluation - established patient (D0120) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 28, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 20, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the refractive service should be covered since it 
is part of the standard eye examination. You also say that it was very necessary because it demonstrated that 
the enrollee has cataracts. The Plan denied your request. The Plan says this service is considered non-covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed during a routine vision exam. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye refraction (92015) provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the endoscopy procedure provided on 
October 24, 2022. 
 
You asked the Plan to reduce the copayment for the endoscopy procedure. You say that the Plan did not pay 
anything. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for the endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the endoscopy procedure provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve provisional crowns (D2799). 
 
You asked the Plan to pre-approve the provisional crowns. You say that it was an accident when you 
swallowed the crown in December 2022. You also say that you are appealing for the tooth of the side that are 
moving creating a bigger space and can finish the implant. The Plan denied your request. The Plan says you do 
not have any supplemental benefit that will apply to cover this service. The Plan also says that there are already 
four units of fixed bridges approved, and provisional crowns are considered part of that 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. Specifically, the requested service is included as part of a permanent 
crown, and is not approved or paid separately. Therefore, we decided that the Plan does not have to pre-
approve provisional crowns (D2799).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a first intraoral periapical x-ray (D0220) and panoramic 
x-ray (D0330) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that there are no dental providers in your area 
that accept your insurance. The Plan denied your request. The Plan says dental services from an OON provider 
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. 
 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an OON provider. Therefore, we decided that the Plan does not have to pre-approve a first intraoral 
periapical x-ray (D0220) and panoramic x-ray (D0330) to be rendered by an out-of-network (OON) provider.