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

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
March 11, 2023, to March 12, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with 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 $250 
copayment for outpatient hospital services/observation services. 
 
You have been asked to pay a $250 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/observation 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 outpatient hospital services provided on March 11, 2023, to March 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
February 2, 2023, to February 21, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for PCDs have not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from February 2, 2023, to February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2394, D2392) provided on August 
17, 2023. 
 
You asked the Plan to pay for resin-based composites. 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 resin-
based composites (D2394, D2392) provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture - cast metal framework with 
resin denture bases (D5213) provided on July 31, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are distressed about this situation due to the 
fact that you had to have a new partial as a result of an automobile accident 44 years ago. You also say that 
bridges are covered but the partial is not and you cannot function without it. 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 service is not covered under this benefit or  
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the maxillary partial denture - cast metal framework with resin denture bases (D5213) provided on July 31, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on January 03, 
2023, to January 08, 2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you need to be transported by 
ambulance due to a heart condition, you were unaware you had a copayment on 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 a $295 
copayment for ambulance services. 
 
You have been asked to pay a $295 copayment for an 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. The total you owe is $590 ($295 copayment x 2 rides = $590). Therefore, we decided that the Plan 
does not have to waive the copayment for an ambulance ride provided on January 03, 2023, to January 08, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed. 
 
You asked the Plan to pre-approve destruction by neurolytic agent of the genicular nerve branches. You say 
that you are requesting reconsideration based on medical necessity. The Plan denied your request. The Plan 
says your request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve destruction by neurolytic agent of the 
genicular nerve branches. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is considered experimental/ 
investigational therapy and is the subject of ongoing clinical trials. Therefore, the request is deemed not 
medically reasonable and 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 destruction by neurolytic agent of the genicular nerve branches have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, 
genicular nerve branches including imaging guidance, when performed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 8, 2023, to 
April 9, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services provided are not covered. 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was seen in the Emergency Department (ED) for blurred vision. The 
enrollee had a normal neurological exam, a normal magnetic resonance imaging (MRI) of the brain and was 
seen in consultation by Neurology. The enrollee was admitted remained hemodynamically and neurologically 
stable. The documentation did not show that at the time of inpatient admission it was reasonable for the 
admitting physician to expect that the patient's necessary hospital care (including earlier ED and/or observation 
care) would span two midnights with supporting documentation of the patients history and comorbidities, 
signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided April 8, 2023, to April 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote cardiac monitoring to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve remote cardiac monitoring. You say that the provider is in-network. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan and the needed testing 
can be performed within the Plan network. 
 
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 
remote cardiac monitoring to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified fixed prosthodontic procedure (D6999) 
provided on August 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that after being approved for the services, you had a 
$670.40 balance. You say you were told that it was for medication, but they did not explain what medication 
they were referring to. The Plan denied your request. The Plan says the service is not a covered expense. 
 
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 pay for an 
unspecified fixed prosthodontic procedure (D6999) provided on August 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Consumer Directed Personal Assistance Services. 
 
You asked the Plan to pre-approve Consumer Directed Personal Assistance Services. You say that you would 
like to appeal this service. The Plan denied your request. The Plan says Consumer Directed Personal Assistance 
Services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Consumer Directed Personal Assistance Services have not been met. Specifically, we find that the 
services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not 
have to pre-approve Consumer Directed Personal Assistance Services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are in pain and are unable to take opioids 
for pain management. The Plan denied your request. The Plan says a kyphoplasty is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a kyphoplasty. Our reviewer says that a 
kyphoplasty is not medically necessary.  Our physician reviewer found that you have upper and lower back 
pain, cervical pain, and a head injury from a fall while playing pickleball. While the exam revealed tenderness 
at the junction of the lumbar and thoracic spine in the midline, the formal diagnostic imaging studies were not 
provided to corroborate a compression fracture at L1. Additionally, there is no documentation of a progression 
of the body loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Therefore, you do not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the Intracept procedure is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) sowing only modic changes without facet degenerative joint disease 
without stenosis, and the cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
August 12, 2023, to August 14, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. 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 $165 
copayment for inpatient hospital stay. 
 
You have been asked to pay a $165 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital stay 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 were charged $330 ($165 x 2 days). You were not charged a copay for the day of 
discharge. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital 
services provided on August 12, 2023, to August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of radiographic images (D0210) provided 
on August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the service was medically necessary. 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 5, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete series of radiographic images 
(D0210) provided on August 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service 
August 7, 2023. 
 
You asked the Plan to pay for the services provided. You say that the transport was separate from any other 
service provided. The Plan denied your request. The Plan says the payment is included in payment for the 
inpatient hospital services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The records show that the enrollee was an inpatient at the time the services 
were provided. The enrollee was transported from hospital to hospital. The services are not separately payable 
in this case. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
billed for date of service August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups (D2950) and porcelain/ceramic crowns
(D2740) for teeth #9, 10 and 11.

You asked the Plan to pre-approve core buildups and porcelain/ceramic crowns for teeth #9, 10 and 11. 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. Maximus overturned
the Plan's denial based on medical necessity. The Plan requested a reopening and stated that these services
were denied based on benefit limits and not medical necessity. The Plan is correct in this case. Though the Plan
offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit
for the requested services was exhausted on date of service June 9, 2023, when the Plan approved core buildups
and porcelain/ceramic crowns for teeth #6, 7 and 8. Therefore, we decided that the Plan does not have to preapprove
core buildups (D2950) and porcelain/ceramic crowns (D2740) for teeth #9, 10 and 11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83036 billed for date of service August 30, 
2023.

You asked the Plan to pay for the billed code. You say that the documentation substantiates the relevance of 
services. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 83036 was billed with diagnosis codes I12.9, N18.9, E78.5, E55.9, and R5.83. These 
diagnosis codes are not among those covered for this testing. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83036 billed for date of service August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says an appropriate diagnosis code was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 87086 was billed with diagnosis code N52.8. This diagnosis code is not among those 
covered for the testing at issue. Based on this information, we decided that Medicare rules for coverage of the 
billed testing have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87086 billed for date of service June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for an ultrasound provided on July 27, 2023. 
 
You asked the Plan to reduce the deductible for an ultrasound. You say that you cannot afford the cost share. 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay $452.69 towards your deductible for the ultrasound. The item or service you asked 
the Plan to reduce the deductible for falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost 
sharing is a contractual obligation that had not been met at the time an ultrasound was received on July 27, 
2023. Therefore, we decided that the Plan does not have to reduce the deductible for an ultrasound provided on 
July 27, 2023.