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

 
We decided that the Plan does not have to pay for the SNF care provided from June 8, 2023, to July 7,2023. 
 You asked the Plan to pay for the SNF services. You say that the enrollee was eligible for SNF coverage for the 
period in question. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the 
SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the SNF care provided from June 8, 2023, to July 7,2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not aware that treat and release is not covered when not being transported to a hospital or emergency room. The 
Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 8, 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 the ambulance response and treatment with no 
transport provided on June 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Stelara for the enrollee.

You asked the Plan to provide coverage for Stelara. The Plan denied your request. The Plan says the required
step therapy criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and
submitted additional information.

The Plan is correct in this case. Medicare covers Part B medications when they are reasonable and necessary
but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented
such criteria for certain Part B medications. 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 preapprove
Stelara. Our reviewer says that the required step therapy criteria are not met. Our physician reviewer
found the Plan requires a trial of Humira, Xeljanz, or Rinvoq before they will approve the requested drug. In
this case, the enrollee had not tried and failed the required drug(s). There is no documentation provided
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for
the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan
does not have to provide coverage for Stelara for the enrollee.
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 June 20, 2023. 
 You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee was 
discharged from the hospital when they were transported. You also say that the submitted medical records and 
trip notes provide the proof. The Plan denied your request. The Plan says the claim history indicates the 
enrollee was in an inpatient hospital status. 
 
The Plan must follow Medicare rules. Medicare rules say that that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service and ground mileage 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 June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a therapeutic continuous glucose monitor
(CGM) for the enrollee.

You asked the Plan to provide coverage for a therapeutic continuous glucose monitor (CGM). You say that at
the time of the appeal, this device was medically necessary. The Plan denied your request. The Plan says all of
the required Medicare criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and noted at the time of the appeal the enrollee was treated with oral hypoglycemic agents only. The enrollee
did not use insulin and there are no documented episodes of hypoglycemia.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit
with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates at the time of the appeal, the enrollee
did not use insulin with at least three injections daily. Medicare rules for coverage of a therapeutic continuous
glucose monitor (CGM) were not met. Therefore, we decided that the Plan does not have to provide coverage
for a therapeutic continuous glucose monitor (CGM) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
27, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have attached the documents and would like 
the claim reprocessed for payment. 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 June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, fluoride application, and adjunctive pre-
diagnostic test (D1110, D1206, D0431) provided on August 8, 2023. 
 
You asked the Plan to pay for 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 cleanings and fluoride has already 
been exhausted. Coverage for the adjunctive pre-diagnostic test denied correctly as they do not fall within your 
dental 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, certain limitations apply. The record 
shows your benefit for cleanings and fluoride was exhausted on date of service February 23, 2022 and August 
22, 2022 (D1110, D1206). Coverage for the adjunctive pre-diagnostic test denied correctly as they do not fall 
within your dental benefits. Therefore, we decided that the Plan does not have to pay for a cleaning, fluoride 
application, and adjunctive pre-diagnostic test (D1110, D1206, D0431) provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays (72100) and an office visit provided by a 
chiropractor (99203) on May 22, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you called the Plan before seeing the 
provider but were not informed these services would not be covered. The Plan denied your request. The Plan 
says these chiropractic services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-rays (72100) and an office visit provided by a chiropractor (99203) on 
May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral minimally invasive sacroiliac joint fusion 
(27279). 
 
You asked the Plan to pre-approve bilateral minimally invasive sacroiliac joint fusion. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that minimally invasive surgical (MIS) fusion of the 
sacroiliac joint (SIJ) utilizing a lateral transfixation approach is considered medically necessary when certain 
criteria are met. 
 
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 bilateral minimally invasive sacroiliac 
joint fusion. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is no sacroiliac joint instability fracture or lesion. Sacroiliac joint fusion for degenerative back pain is 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral minimally invasive sacroiliac joint fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral minimally invasive sacroiliac joint 
fusion (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 3, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was your first cleaning in 
2023 and you are not sure why the claim was denied. You also say that the previous cleaning was in November 
of 2022 and in August this year. The Plan denied your request. The Plan says your benefit for the 
comprehensive oral evaluation 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 service was exhausted on date of service February 3, 2021. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) and the application of fluoride (D1208) 
provided on June 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that someone from the Plan said you can get as 
many cleanings you want per year. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 cleaning (D1110) and the application of fluoride (D1208) on January 12, 2023, and 
April 26, 2023; therefore, your benefit for the requested items or services was exhausted on the date of service 
of April 26, 2023. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) and the 
application of fluoride (D1208) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0330) on June 27, 2023. 
 
You asked the Plan to pay for the dental service (D0330). You say that you would like to request 
reconsideration for payment. 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 November 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental service (D0330) on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  a limited oral evaluation-problem focused 
and a perioapical-1st radiographic image provided on July 18, 2023. 
 
You asked the Plan to waive the coinsurance for  a limited oral evaluation-problem focused and a perioapical-
1st radiographic image. You say that this should be covered. 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 50% 
coinsurance for Class 2 Basic Services. 
.  
 
 You have been asked to pay 50% coinsurance for a limited oral evaluation-problem focused and a perioapical-
1st radiographic image. This item/service falls within the Class 2 Basic 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 coinsurance for  a limited oral evaluation-problem focused and a perioapical-1st 
radiographic image provided on July 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 7, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are not a hospital provider, and that you are 
not required to participate or enrollee into Medicare. 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 June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment 
(98942) rendered by an out-of-network (OON) provider on June 5, 2023.  
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an 
out-of-network provider, without prior authorization.  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.   
 
 
 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to issue reimbursement for the chiropractic manipulative treatment (98942) rendered by an out-
of-network (OON) provider on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for filings (D2330) provided on May 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for filings (D2330) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids (V5261) provided on 
November 8, 2022.  
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $999 
copayment per aid for premium hearing aids.  
 
You have been asked to pay a $1,998 copayment ($999 x 2) for the premium hearing aids provided. 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 hearing aids (V5261) provided on 
November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), a 
prefabricated abutment (D6056) and an implant supported to crown (D6065) for tooth #3, #4, #5, #6, #7, #11, 
and #12. 
 
You asked the Plan to pre-approve the dental services. You say that the implants are medically necessary so 
you can eat. 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 implant body (D6010), a prefabricated abutment (D6056) and an implant supported to 
crown (D6065) for tooth #3, #4, #5, #6, #7, #11, and #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported to crown (D6061) for tooth #30 
and #31. 
 
You asked the Plan to pre-approve the dental services. You say that your provider said the dental procedures is 
the best course of action. 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 an 
abutment supported to crown (D6061) for tooth #30 and #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the device was ordered to improve the enrollee's 
quality of life. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.