Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a steroid injection to be provided by an OON provider.  
 
You asked the Plan to pre-approve a steroid injection to be provided by an OON provider. . You say that you 
have seen this provider before and would like to see him again. The Plan denied your request. The Plan says 
OON providers are 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a steroid injection to be provided by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to provide coverage for an additional 12 visits for continued outpatient
physical therapy.

You asked the Plan to provide coverage for the therapy services. You say that at the time of the appeal, the
requested visits were medically necessary. The Plan denied your request.

The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the medical
records show the enrollee had received 90 therapy visits for treatment of Parkinson's disease. The records show
at this point, this treatment is maintenance and did not require a skilled level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy. Based on the medical records provided, the enrollee's continued maintenance could have been
achieved with home exercise or home assistance and did not require an outpatient skilled level of care.
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan
does not have to provide coverage for an additional 12 visits for continued outpatient physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve surgical placement of implant body (D6010). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says your Plan does not cover this 
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 pre-approve 
surgical placement of implant body (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 2 continuous glucose monitor (CGM) 
replacement. 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee already has authorization from February 6, 2023, to February 5, 2024 for 12 units. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
 
  The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a freestyle libre 2 continuous glucose monitor (CGM) replacement.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport provided on June 3, 
2023. 
 
You asked the Plan to pay for ambulance services without transport. You say that you were told by the treating 
paramedic that it would be cheaper if your husband drove you to the emergency room. The Plan denied your 
request. The Plan says without transport there are no payable services. 
 
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 June 3, 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 ambulance services without transport provided on 
June 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health and wellness services to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve mental health and wellness services. You say that you say that you would 
like to be referred out of plan, because you are a former employee who feels that there will be no 
confidentiality and wants to use your supplemental coverage. The Plan denied your request. The Plan says the 
enrollee must receive their care from a network provider (for more information about this, see Section 2 of 
Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is not 
part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
mental health and wellness services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on August 4, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the requested ambulance services.  The Plan denied your request. The Plan says our policy covers non-
emergency ambulance transportation when it is the only way to transport a member safely and adequately or if 
other means of transporting a member are unsafe due to a medical condition. This claim does not meet these 
requirements.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary.  Our physician reviewer found other means of transport were not contraindicated for the enrollee. The 
ambulance transport was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance service, basic life support, non-emergency transport, and ground mileage 
provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services on July 5, 2022, to, December 27, 
2022. 
 
You asked the Plan to pay for the acupuncture services. You say that the Plan has reimbursed you for this 
expense. The Plan denied your request. The Plan says  that the acupuncture services were provided by an 
unqualified provider. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for acupuncture services on July 5, 2022, to, December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 15, 2023 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 provided by an out-of-network provider on February 15, 2023
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 9, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you have attached the documentation and would 
like the claim reprocessed. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core build-up (D2950) provided on 
May 30, 2023. 
 
You asked the Plan to pay for D2740 and D2950. You say that you needed this dental work. 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 crown 
(D2740) and core build-up (D2950) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not told that you would owe this 
much. The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service January 3, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on July 3, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that the provider representative told you 
that your hearing aids could be covered by insurance, or at least partial. You also say that you went and 
borrowed the money. The Plan denied your request. The Plan says the hearing benefit is not covered if the 
services are not registered in advance. The Plan also says that hearing aids ordered through providers other than 
the Plan Hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D4341). 
 
You asked the Plan to pay for the dental service (D4341). You say that you would like to request 
reconsideration of the denied dental service (D4341). 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 the dental service (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral image (D0230) provided on June 26, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you have not had x-rays since 2017. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 26, 2023. Therefore, 
we decided that the Plan does not have to pay for an additional intraoral image (D0230) provided on June 26, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of the implant body (D6010) for 
tooth #7, #8, #9, #18, #28, and #29. 
 
You asked the Plan to pre-approve the dental services. You say that the requested implants are necessary to 
better your quality of life. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all associated services 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 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 pre-approve the 
surgical placement of the implant body (D6010) for tooth #7, #8, #9, #18, #28, and #29.  
 
Your complaint about the Plans dental coverage is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5258) provided on June 6, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5258). You say that at no time did anyone inform you that 
there was a "hearing provider" which was different from a "network provider." You also say that you were 
never told that you needed to call back to get another referral. The Plan denied your request. The Plan says the 
hearing benefit is not covered if the services are not registered in advance. The Plan also says that hearing aids 
ordered through providers other than the Plan hearing network providers are not covered 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5258) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5258) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental service. You say that the evaluation was the first time you received 
service from the provide the service could not exceed the frequency limitation. 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 the Plan paid for a limited oral evaluation (D0140) on May 9, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of May 9, 2023. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation (D0140) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided on June 8, 2023 
 
You asked the Plan to pay for D9310. You say that this is the first time you have seen this provider. The Plan 
denied your request. The Plan says the denied dental service is not a covered benefit. 
 
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 
diagnostic consultation (D9310) provided on June 8, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3010, L3410).  
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as you disagree 
with the denial. 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 (L3010, L3410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete mandibular dentures (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 14, 2021. Therefore, 
we decided that the Plan does not have to pre-approve complete mandibular dentures (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam (D2140) and local anesthesia (D9215) provided 
on January 30, 2023. 
 
You asked the Plan to pay for D2140 and D9215. You say that you are not satisfied with the services you 
received. 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 an 
amalgam (D2140) and local anesthesia (D9215) provided on January 30, 2023.