Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 18, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. 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 psychotherapy provided 
on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6750 x3), pontic (D6240 x2), 
extraction (D7210) and fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 
retainer crown (D6750 x3), pontic (D6240 x2), extraction (D7210) and fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded progressive lenses (V2199). 
 
You asked the Plan to pre-approve the upgraded progressive lenses (V2199). You say that you have become 
accustomed to wearing wider focus progressive lenses and standard progressive lenses would be difficult and 
uncomfortable. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 standard frames and lenses. 
 
We looked at the file and the Plan's rules. Specifically, the service is considered an upgrade which is not a 
covered benefit. Based on this information, we decided that the Plan's rules for coverage of the upgraded 
progressive lenses (V2199) have not been met. Therefore, we decided that the Plan does not have to pre-
approve the upgraded progressive lenses (V2199).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D7956), the surgery for 
a bone graft (D7950), and the sample of tooth or bone tissue from the mouth for biopsy (D7285). 
  
You asked the Plan to pre-approve the guided tissue regeneration (D7956), the surgery for a bone graft 
(D7950), and the sample of tooth or bone tissue from the mouth for biopsy (D7285). You say that you need 
these services done on your done to prevent your jaw from breaking when chewing. The Plan denied your 
request. The Plan says the 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 guided tissue regeneration 
(D7956), the surgery for a bone graft (D7950), and the sample of tooth or bone tissue from the mouth for 
biopsy (D7285) are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve the guided tissue regeneration (D7956), the surgery for a bone graft (D7950), and the 
sample of tooth or bone tissue from the mouth for biopsy (D7285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on January 05, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on January 05, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided outside of the United 
States from May 1, 2022, to December 1, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you were not able to fly back to the 
United States for treatment. The Plan denied your request. The Plan says these services were not urgent or 
emergent. 
 
The Plan must follow Medicare rules. Medicare rules say that with limited exceptions, items and services 
furnished outside the United States are excluded from coverage. However, the Plan offers a transportation 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan 
covers services outside of the United States when they are urgent of emergent. 
 
We looked at the file and Medicare rules. The physical therapy services at issue were not urgent or emergent. 
Based on this information, we decided that Medicare rules for coverage of physical therapy services have not 
been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided 
outside of the United States from May 1, 2022, to December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a CT scan of a lower extremity.

You asked the Plan to provide coverage for a CT scan. The Plan denied your request. The Plan says the
required coverage criteria are not met. Maximus overturned the Plans denial stating if the MAKO procedure is
approved the CT scan will be needed for planning purposes. The Plan requested a reopen and stated approval of
the MAKO procedure had not yet been reviewed by the Plan and Maximus cannot approve services in
anticipation of the possibility of another service being requested or approved.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. At the time of the appeal, the MAKO procedure had
neither been requested nor denied for approval by the Plan, therefore, approving a CT scan only needed for a
procedure not yet addressed was done so in error. Therefore, we decided that the Plan does not have to provide
coverage for a computed tomography (CT) scan of a lower extremity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a tendon procedure provided on August 
29, 2023. 
 
You asked the Plan to reduce the copayment for a tendon procedure. You say that this was supposed to be a 
$250 charge, not $300. You were not in the hospital building, it has a different address. 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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for a tendon procedure. This item/service falls within the 
outpatient hospital 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 reduce the copayment for a tendon 
procedure provided on August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs or non-routine services for durable medical 
equipment (DME) other than oxygen equipment (K0739) and additional items and accessories (codes E0978, 
E1004, E1028, E2310, E2311, E2313, E2376, E2620, and K0108 x5). 
 
  You asked the Plan to pre-approve repairs or non-routine services for DME and additional items and 
accessories. You say that this is a modification to the enrollee's current power wheelchair due to change in 
condition. The Plan denied your request. The Plan says Medicare does not cover repairs when the expense for 
repairs exceeds the estimated expense for replacement of the wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. The record shows that the cost of the requested repairs is $5,516.78, 
and the prior dollar history of repairs made to this wheelchair: $15,419.85. The replacement cost for the chair 
as currently configured is $14,291.83. Based on this information, we decided that Medicare rules for coverage 
of repairs or non-routine services for DME and additional items and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve repairs or non-routine services for durable medical 
equipment (DME) other than oxygen equipment (K0739) and additional items and accessories (codes E0978, 
E1004, E1028, E2310, E2311, E2313, E2376, E2620, and K0108 x5).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 24, 2023, to 
September 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 24, 2023, to September 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 2, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 2, 2023.
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 Intracept procedure is medically 
necessary. 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 requested the Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found detailed documentation is not evidenced regarding Modic changes at the requested 
levels. In this case, there were/are multiple plausible pathologic sources of significant pain generation. The 
bilateral low back and leg pain, the noted pain-aggravating factors (prolonged standing, sitting, and walking), 
pain-relieving factors (stretching, leaning forward, and activity modifications), and decreased sensation in the L4 and L5 dermatomes were/are all non-specific to any pathologic entities. Overall, documentation is lacking 
regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L4 and L5, in this case, is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213) and partial lower denture 
(D5214). 
 
You asked the Plan to pre-approve partial upper and lower dentures. 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 pre-approve 
partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup, including any pins when required 
tooth #'s 6, 9, 10, and 11 (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that you would like to receive the crowns after the 
root canals which have already been approved. You also say that you are in pain and have started the 
prescribed antibiotics, Tylenol and Motrin. The Plan denied your request. The Plan says this service is not 
covered in your dental 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 pre-approve the 
core buildup, including any pins when required tooth #'s 6, 9, 10, and 11 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the application of 
fluoride (D1206), and the periodontal maintenance (D4910) provided on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that since you cannot get a basic cleaning you would 
like the Plan to cover the amount for a basic cleaning. The Plan denied your request. The Plan says your benefit 
for the periodic oral evaluation has already been exhausted. Also, the application of fluoride and the 
periodontal maintenance 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, certain limitations apply. The record 
shows the Plan paid for a periodic oral evaluation (D0120) on January 3, 2023; therefore, your benefit for the 
periodic oral evaluation was exhausted on the date of service of January 3, 2023. The application of fluoride 
and the periodontal maintenance are not covered under the Plan's dental benefit. Therefore, we decided that the 
Plan does not have to pay for a periodic oral evaluation (D0120), the application of fluoride (D1206), and the 
periodontal maintenance (D4910) provided on September 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest provided on  
August 16, 2023. 
 
You asked the Plan to pay for the radiologic examination of the chest. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the member has a primary health insurance plan 
effective April 1, 2021 to present. The Plan says that until the Plan receives the Explanation of Benefits (EOB) 
from the primary insurance, the Plan is unable to process the claim towards payment. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made a total 
of four outreaches to the appellant to notify the provider of the member's primary insurance, and outreach 
attempts were made to the members primary insurance company to obtain the EOB. As the secondary insurer, 
the Plan cannot be held responsible for the radiologic examination of the chest until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for a radiologic 
examination of the chest provided on August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an enteral nutrition infusion pump 
provided on April 07, 2023, to May 24, 2023. 
 
You asked the Plan to waive the coinsurance for an enteral nutrition infusion pump. You say that you can only 
eat small soft foods and need this item, but the amount cannot be this high. 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 20% 
coinsurance for durable medical equipment (DME) and related services. 
 
You have been asked to pay 20% coinsurance for an enteral nutrition infusion pump. This item/service falls 
within the durable medical equipment (DME) and related 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 $2,860.38. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an enteral nutrition infusion pump provided on 
April 07, 2023, to May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3330). 
 
You asked the Plan to pre-approve endodontic therapy. 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 pre-approve 
endodontic therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered in full. The Plan 
denied your request. The Plan says your $3,500 annual maximum will be exhausted during 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, certain limitations apply. The record 
shows your $3,500 annual maximum will be exhausted. Therefore, we decided that the Plan does not have to 
pre-approve maxillary partial denture (D5213).