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

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), the 
surgical access to an implant body (D6011), a prefabricated abutment (D6056), implants (D6110, D6114, and 
D6115), and an implant supported retainer (D6120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the denied dental services 
approved so you can get permanent teeth to help you chew food. The Plan denied your request. The Plan says 
the denial of authorization for these services is correct, because implants and all services related to implants are 
not covered by the Plan. 
 
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 pre-approve the 
surgical placement of implant body (D6010), the surgical access to an implant body (D6011), a prefabricated 
abutment (D6056), implants (D6110, D6114, and D6115), and an implant supported retainer (D6120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the wound care services provided on 
December 01, 2022, to December 08, 2022. 
 
You asked the Plan to reduce the copayment for the wound care services. You say that you were informed that 
your copayments would only be $50. 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 surgery services at a hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for the wound care services. This item/service falls within the 
surgery services at a hospital outpatient facility 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. You have been asked to pay $204.17 for each of the 3 visits, for a 
total of $612.51. Therefore, we decided that the Plan does not have to reduce the copayment for the wound care 
services provided on December 01, 2022, to December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the fitting and insertion of a vaginal 
support device provided on December 08, 2022. 
 
You asked the Plan to reduce the copayment for the fitting and insertion of a vaginal support device. You say 
that the surgery was rendered in the providers office. 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 $250 
copayment for in-network outpatient surgery and other medical services provided at hospital outpatient 
facilities.  
You have been asked to pay a $250 copayment for the fitting and insertion of a vaginal support device. This 
item/service falls within the in-network outpatient surgery and other medical 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. The record shows that you received surgery services provided at a hospital facility. However, since 
the allowed amount is less than the standard copayment, you only owe $249.70. Therefore, we decided that the 
Plan does not have to reduce the copayment for the fitting and insertion of a vaginal support device provided on 
December 08, 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. The Plan denied your request. The Plan says the information we 
have about the enrollee's condition does meet all the requirements for inpatient rehabilitation, services needed 
may be provided safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397). 
 
You asked the Plan to pay for the knee orthosis and sleeve. You say that the items should be covered. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication in the medical records submitted that the braces were discusses, needed, or ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension 
sleeve (L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit 
provided on February 02, 2023. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that you were 
only there a few minutes and do not think you should have to pay. 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 $10 
copayment for primary care provider/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care provider office visit. This item/service falls 
within the primary care provider/practitioner 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 the primary care provider office visit provided on February 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on June 22, 2022. 
 
You asked the Plan to pay for the services. You say that this claim should be reprocessed. The Plan denied your 
request. The Plan says the clinical information does not support the specific Medicare coverage requirements 
for an expanded gastrointestinal infectious disease pathogen panel. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the reviewed documentation indicates that the clinical information does not support the specific 
Medicare coverage requirements for an expanded gastrointestinal infectious disease pathogen panel. The point 
of origin was clinic or physician's office. The enrollee was diagnosed with noninfectious gastroenteritis. The 
review has determined that the enrollee did not meet the criteria for this testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services rendered on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2394) and a crown 
(D2740) for tooth #4 and #15 provided by an out-of-network provider on September 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan keeps denying all the dental 
claims and you would like them to pay for the covered dental services. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. 
 
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 enrollee has been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2394) and a 
crown (D2740) for tooth #4 and #15 provided by an out-of-network provider on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracorporeal photopheresis (ECP) provided to the enrollee on June 30, 2022.
You asked the Plan to pay for the ECP. You say that this should be paid for. The Plan denied your request. The Plan says that there was no documentation that this was provided for bronchiolitis obliterans syndrome (BOS) under a clinical research study or any of the other indications.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also state that extracorporeal photopheresis is covered for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study. We find that the claim was not submitted with a unique identification code to confirm the enrollee is enrolled in a clinical trial. Based on this information, we decided that Medicare rules for coverage of the ECP have not been met. Therefore, we decided that the Plan does not have to pay for the extracorporeal photopheresis (ECP) provided to the enrollee on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed for date of service 
September 1, 2021. 
 You asked the Plan to pay for procedure codes 88360 and 88381. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these codes are included in the facility payment and are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88360 and 88381. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT codes 88360 and 88381. Based 
on this information, we decided that Medicare rules for coverage of procedure code 88360 and 88381 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed 
for date of service September 1, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from October 1, 2022, to October 9, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the NOA is 
required to match the same date on the claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services stating the admission date on the claim at issue is 
October 1, 2022. However, the submitted claim shows an admission date of September 1, 2022. The Plan has 
not submitted the NOA to show that the admission dates do not match. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the home health services provided from October 1, 2022, to 
October 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 15, 
2022. 
 
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 on date of service May 12, 2022. Therefore, 
we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 15, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from  
November 23, 2021, to December 1, 2021, at the DRG 190 originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG 190 originally billed. You say that the 
medical records support payment of DRG 190. The Plan denied your request. The Plan says the medical record 
does not support coverage for DRG 190. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis codes J96.01, acute 
respiratory failure, not elsewhere classified Type 2 [with hypercapnia] and J96.02, acute and chronic 
respiratory failure. 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 pay for the inpatient hospital 
services at the DRG 190 originally billed. Our reviewer says that the medical record does not support the billed 
DRG 190. Our physician reviewer found that in this case, there was no clinical or laboratory evidence of acute 
respiratory failure. The review has determined that the documentation does not support the secondary diagnosis 
codes J96.01, acute respiratory failure, not elsewhere classified Type 2 [with hypercapnia] and J96.02, acute 
and chronic respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from November 23, 2021, to December 1, 2021, at the DRG 190 
originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 1, 2022.

You asked the Plan to pay for the eye refraction. You say that a refraction is a covered benefit. The Plan denied your request. The Plan says this service (refraction) is only covered when a routine eye examination is performed. Maximus overturned the Plan's denial. The Plan requested a reopening and stated Maximus did not apply the correct criteria.

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 they are part of a routine eye exam.

We looked at the file and the Plan's rules. The file indicates you did not have a routine eye exam. The 
EOC clearly states that refraction is covered as part of a routine eye exam, which is not the case in this instance. 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 August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services with an out-of-network (OON) provider on 
April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told this was in network and would 
like this to be covered. 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 dental services with an out-of-network (OON) provider on April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minuteman procedure. 
 
You asked the Plan to pre-approve the minuteman procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is experimental. 
 
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 minuteman procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the 'gold standard' of lumbar fusion. There is a lack of large-volume, 
long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition 
as discussed above.  
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 minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the minuteman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services billed with Patient-Driven Payment 
Model (PDPM) BDMD1 for date of service June 9, 2021, to June 12, 2021. 
 
You asked the Plan to pay for the inpatient services billed with PDPM BDMD1. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the PDPM billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate PDPM for payment. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient services billed with PDPM BDMD1. Our 
reviewer says that the documentation does not support the PDPM billed. Our reviewer found the enrollee was 
admitted to a brief stay in a facility. A mini nutrition assessment dated June 9, 2021, was submitted for review. 
Criteria for malnutrition are not met in that document as weight loss is not documented and the enrollee's body 
mass index is above 18. Therefore, the PDPM billed is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services billed with PDPM BDMD1 have not been met. Therefore, 
we decided that the Plan does not have to pay for the inpatient services billed with Patient-Driven Payment 
Model (PDPM) BDMD1 for date of service June 9, 2021, to June 12, 2021.