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

 
We decided that the Plan does not have to issue additional reimbursement for the health club membership fees 
(S9970) purchased on January 7, 2022 and February 17, 2022. 
 
You asked the Plan to issue additional reimbursement for these fees. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for this service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the Plans contract states that the Plan reimburses you up to $250 per 
calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan issued 
reimbursement to you in the amount of $250 ($226.94 + $23.06) for this membership. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to issue 
additional reimbursement for the health club membership fees (S9970) purchased on January 7, 2022 and 
February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on February 
2, 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 the services 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, 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 
mandibular partial denture (D5214) provided on February 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services and injections provided on February 17, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for physician services and injections. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services were not emergent in nature. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services and injections provided on 
February 17, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device.  
You asked the Plan to pre-approve CGM. You say that this would make your quality of life much more 
comfortable. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service October 18, 
2022.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 
billed for date of service October 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the 
administration of the drugs provided on March 10, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the administration of the drugs. You 
say that you are on a limited income and are unable to afford the cost share applied. 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 Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and the administration of the drugs. This 
item/service falls within the Medicare Part B Prescription Drugs 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 $2,189.88, which is 20% of 
the allowed amount for the chemotherapy drugs and the administration of the drugs ($10,949.39 allowed x 20% 
= $2,189.88). Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy 
drugs and the administration of the drugs provided on March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
10, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you needed another denture 
readjustment because the provider who did the original adjustment did not get the denture to fit right. The Plan 
denied your request. The Plan says your benefit for the panoramic radiographic image has already been 
exhausted. Procedure code D0210 service was rendered on May 3, 2021. 
 
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 panoramic radiographic image was exhausted on date of service May 3, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an OON provider.  
 
You asked the Plan to pre-approve the physician services. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says these services can be provided in-
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 Plans POS 
benefit only applies to non-Medicare covered dental services. 
 The record shows that you are 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 physician 
services to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Q4190/Artacent AC, per sq cm (1280) Q4169/Artacent wound, per sq cm (1280).

You asked the Plan to provide coverage for this application . You say that this treatment is medically necessary.  The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not review the correct service. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Q4190/Artacent AC, per sq cm (1280) Q4169/Artacent wound, per sq cm (1280). The enrollee is a 56-year-old man with end-stage cardiomyopathy requiring a left ventricular assist device (LVAD). On February 18, 2023, the enrollee underwent heart transplant and explant of the LVAD. In March 2023, the enrollee developed a perforated duodenal ulcer with erosion into the pancreas, causing hemorrhage. A right hemicolectomy was performed with end ileostomy, and a J-tube was placed. Subsequently, the enrollee returned to the OR for washout and closure. The enrollee has a large abdominal wound dehiscence and was admitted for a comprehensive rehabilitation program on April 27, 2023. On May 1, 2023, the abdominal wound measured 22 cm x 11 cm x 1 cm deep. Artacent Wound is a wound specific, dual-layer amniotic graft designed for covering diabetic foot ulcers, pressure injuries, venous stasis ulcers, burns, or post-Mohs surgery. 
The Plan is correct in this case. The documentation does not support that the enrollee in this case has an indication for Q4190/Artacent AC, per sq cm (1280) Q4169/Artacent wound, per sq cm (1280). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this application have not been met. Therefore, we decided that the Plan does not have to provide coverage for Q4190/Artacent AC, per sq cm (1280) Q4169/Artacent wound, per sq cm (1280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), bitewings x-rays-four 
radiographic images (D0274), intraoral-periapical first radiographic image (D0220), intraoral-periapical 
additional radiographic image (D0230), periodic oral evaluation (D0120), and the topical application of 
fluoride varnish (D1206) provided on February 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. Additionally, you have exhausted the allowable benefit 
for the intraoral-periapical additional radiographic image provided in this case.  
 
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. 
Additionally, the Plans contract states that one intraoral-periapical radiographic image is covered per year. On 
this day, two intraoral-periapical radiographic images were provided, in which one was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for the additional intraoral-periapical radiographic image 
provided. Therefore, we decided that the Plan does not have to pay more for the dental cleaning (D1110), 
bitewings x-rays-four radiographic images (D0274), intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic image (D0230), periodic oral evaluation (D0120), and the topical 
application of fluoride varnish (D1206) provided on February 2, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 6, 2022, 
through December 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was brought to the emergency department (ED) on December 6, 2022 by Emergency 
Medical Services (EMS) after having a seizure after a fall. She was lethargic and confused and was evaluated 
in the ED and found to be post-ictal with tremors in the upper extremities and cogwheel rigidity. She was 
admitted to telemetry and evaluated by Neurology and Psychiatry. She underwent a computed tomography 
(CT) scan of the brain and cervical spine, electrocardiogram, and an electroencephalogram. She was treated 
with intravenous Lorazepam and Lamotrigine. The enrollees condition stabilized and improved and she was 
discharged on December 8, 2022 when she was considered medically stable. The review has determined that 
the record showed that at the time of the inpatient admission the admitting physician reasonably expected that 
the enrollees necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from December 6, 2022, through December 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on December 14, 2022, 
by an out-of-network provider. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were unaware the provider was 
out-of-network and believe the cost share applied is incorrect. 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 30% 
coinsurance for out-of-network advanced imaging services.  
 You have been asked to pay a $150 copayment for a CT scan. The copayment applied is less than the standard 
amount for a CT scan performed by an out-of-network provider because the Plan applied the cost share for an 
in-network CT scan. This item/service falls within the outpatient diagnostic tests 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 a CT scan provided on December 14, 2022, by an out-of-network 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says 6 visits have been approved, and 10 remain denied as 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental surgery procedure (41899) and the anesthesia 
for intraoral procedures, including biopsy (00170). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the dental surgery 
procedure (41899) and the anesthesia for intraoral procedures, including biopsy (00170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this service 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 March 20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received on November 28, 2022, 
through December 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that the enrollee qualified for the services. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services received on November 28, 2022, 
through December 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental crowns-porcelain fused to high noble metal for teeth 
number 22, 23, 24, 25, 26, 27, 28 (D2750 x 7). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested dental items are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan is responsible for obtaining dental records from their 
network provider, who is an agent of the plan. The plan has not provided any evidence of their attempts to 
receive these records. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pre-approve dental crowns-porcelain fused to high noble metal for 
teeth number 22, 23, 24, 25, 26, 27, 28 (D2750 x 7).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.