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

 
We decided that the Plan does not have to pay for a fixed bridge (D6750, D6240) for teeth #28 to #31. 
 
You asked the Plan to pay for a fixed bridge. You say that this bridge is necessary as you are unable to chew 
and experiencing pain. The Plan denied your request. The Plan says the Plan's criteria for a fixed bridge are not 
met in this case. Additionally, there is an existing bridge with no evidence of decay or missing bridge to 
support the need for replacement. 
 
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. The Plan covers a fixed bridge 
in certain circumstances when the bridge is requested to replace one upper front tooth or two adjacent lower 
front teeth when there are no other teeth missing in the same arch.  
 
We looked at the file and the Plan's rules. The bridge in this case is requested for posterior (back) teeth. Based 
on this information, we decided that the Plan's rules for coverage of a fixed bridge have not been met. Therefore, 
we decided that the Plan does not have to pay for a fixed bridge (D6750, D6240) for teeth #28 to #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on January 6, 2022. 
 
You asked the Plan to pay for the dental item. You say that you were under the impression that you had dental 
coverage for dentures. You say that you did not find out until after you received the denture that it is not 
covered. You also say that you would like this to be covered. The Plan denied your request. The Plan says there 
is no coverage for new partial denture for the 2022 benefit period. 
 
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 lower partial denture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the lower partial 
denture (D5214) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on January 4, 2022, 
by the out of network provider. 
 
You asked the Plan to pay for the dental service. You say that this is the first time you have used your dental 
coverage. You say that you were shocked to find out your dentist was out of network. You say that you live on 
a fixed income. You say that this bill has caused you undue hardship. You also say that you would like a one-
time exception to be made. The Plan denied your request. The Plan says dental services received out of 
network are not covered. 
 
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 porcelain crown is not among 
those covered under this benefit when receive out of network. Therefore, we decided that the Plan does not have to 
pay for the porcelain crown (D2740) provided on January 4, 2022, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 30, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that you did not know that the treating provider was not 
in-network. The Plan denied your request. The Plan says this claim was received after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the prophylaxis was not filed until February 1, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the prophylaxis (D1110) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210), the limited oral evaluation (D0140), the placement of an 
intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922), the bone 
replacement graft for ridge preservation-per site (D7953), and the guided tissue regeneration-resorbable barrier, 
per site (D4266) provided on February 17, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy.   
 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 services provided in this case are 
not among those covered under this benefit. Additionally, the tooth extraction provided in this case is a covered 
benefit by the Plan; however, the service was rendered by an out-of-network provider. Enrollees pay 100% of 
the cost for covered dental services rendered by an out-of-network provider. Therefore, we decided that the 
Plan does not have to issue reimbursement for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), the limited oral evaluation (D0140), the placement of an intra-socket 
biological dressing to aid in hemostasis or clot stabilization, per site (D7922), the bone replacement graft for 
ridge preservation-per site (D7953), and the guided tissue regeneration-resorbable barrier, per site (D4266) 
provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided by an 
out-of-network provider on November 3, 2021. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided by an out-of-network provider on November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone density DEXA scan (77080). 
 
You asked the Plan to pre-approve a bone density DEXA scan. The Plan denied your request. The Plan says the 
requested DEXA bone density study does not appear to be medically reasonable and 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 bone density DEXA scan. Our 
reviewer says that the requested a bone density DEXA scan is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 74-year-old female with 
asymptomatic menopausal state documented in chart. DEXA was already performed less than 2 years prior. A 
repeat DEXA scan was requested. Thyroid testing essentially normal. Based on the current guidelines for 
DEXA scans supporting every 2-year screening for a patient with the same history and medical circumstances 
as this patient, there is insufficient support made to prematurely complete a repeat DEXA when it has not yet 
been two years since the prior DEXA was completed. Therefore, this request for DEXA scan will be 
considered not medically necessary at this time.  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 bone density DEXA scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone density DEXA scan (77080).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whole-body positron emission tomography (PET) scan 
(78816). 
 
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a PET scan is not covered in this situation. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that the 
enrollee does not have an indication for which a PET Scan can be covered at this time. Our physician reviewer 
found the records do not show that a bone scan has been done. Current guidelines state that in enrollees with 
prostate cancer, a high risk for metastatic disease, and negative conventional imaging, clinicians may obtain 
molecular imaging to evaluate for metastases. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a whole-body positron emission tomography (PET) scan (78816).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation 
(D4921), and periapical x-rays (D0220, D0230) provided on December 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentist said he verified your benefits over 
the phone with your plan before your appointment. You also say that the services should be covered. The Plan 
denied your request. The Plan says periodontal maintenance, gingival irrigation, and periapical x-rays are not 
listed as 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 periodontal maintenance, gingival 
irrigation, and periapical x-rays are not among those covered under this benefit. Additionally, the Plan confirmed that the provider did contact them only to clarify the dental plan you were enrolled in. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation 
(D4921), and periapical x-rays (D0220, D0230) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 4, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on July 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are unstable and require additional short-term acute care services that can be 
safely administered at the current facility until more stable and appropriate for a lower level of care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cat 5Vx ultra lightweight wheelchair with Nu Motion 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an ultra-lightweight wheelchair. You say that you do not agree with the 
denial and are requesting services be covered for a custom wheelchair. The Plan denied your request. The Plan 
says you must use in-network providers for services to be covered at cost-sharing levels unless the care needed 
is too complex, not available, or of an unforeseen, urgent/emergent matter. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cat 5Vx ultra lightweight wheelchair with Nu Motion to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
April 28, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 3. This indicator identifies stand-alone codes that describe the 
technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an 
associated code that describes the professional component of the diagnostic tests only. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 
provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a denture adjustment (D5421 and D5411), and a limited oral 
evaluation (D0140), provided by a participating provider on February 23, 2022. 
 
You asked the Plan to pay for a denture adjustment and a limited oral evaluation. You say that you would not 
have had to get these services done if the dentures were done correctly the first time. The Plan denied your 
request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a denture 
adjustment (D5421 and D5411), and a limited oral evaluation (D0140), provided by on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on February 
16, 2021. 
 
You asked the Plan to pay for the dental item. You say that you were not informed that you would no longer 
have coverage for dentures in 2022. You say that you had already started the process. You also say that you 
want to have the impression service reimbursed. The Plan denied your request. The Plan says complete lower 
denture is not listed as 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 complete lower denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete lower denture (D5120) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement toward the $115 paid out of pocket for
vision services provided on August 11, 2021.
You asked the Plan to pay additional reimbursement. You say that you paid $115, and the Plan should
reimburse you in full for these services. The Plan denied your request. The Plan says you were reimbursed the
Medicare allowable for out of network vision services. Maximus overturned the Plans denial for insufficient
information regarding the charges. The Plan requested a reopen and provided additional information. The Plan
provided documentation to show you had a routine vision exam provided out of network. You paid $115 out-of-
pocket and submitted a reimbursement request. However, the Plan can only make payment according to the
out-of-network fee schedule guidelines provided by Medicare. Per the fee schedule, the allowed amount was
$35 therefore, the payment to you was $35.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says if you use out of network providers the cost
of your services may be higher.
Health plans are only allowed to pay Medicare providers and reimburse enrollees for the Medicare allowed
amounts Medicare will pay for services billed. Any over payment made to a provider who accepts the Medicare
allowed amount must be reimbursed by the out of network provider, not the health plan. The Plan reimbursed
you the Medicare allowed amount they would have paid. Any further reimbursement would be an issue
between you and the out of network provider. Therefore, we decided that the Plan does not have to pay
additional reimbursement toward $115 paid out of pocket for vision services provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 21, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
provided at in-network benefit level to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CGM and supplies provided at in-network benefit level. You say that 
these items are medically necessary. The Plan denied your request. The Plan says that there are participating 
providers available to provide these items. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be 
higher. 
 
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 services at an in-network level of care. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies provided at in-network benefit level 
to be provided by an out-of-network (OON) provider.