Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for a telehealth visit provided on December 14, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. Maximus administratively overturned the denial for an incomplete case file submission. The Plan requested a reopen and provided a complete case file for review.
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 that you must pay $25 copayment for in office or telehealth specialist visits. A psychiatrist is a specialist. 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 $25 copayment charged for a telehealth visit provided on December 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says because hospice claims cannot be split, the provider should have submitted two claims. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. 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 from October 29, 2021, to October 31, 2021. Therefore, one claim should have been sent to Original Medicare for those dates and a separate claim should have been submitted to the Plan for November 1, 2021, to November 27, 2021. Therefore, we decided that the Plan does not have to pay for home health services billed entirely on one claim.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from January 31, 2021, to March 1, 2021.
You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says since a hospice claim cannot be split, one claim should have submitted to Original Medicare for January 31, 2021, and one claim should have been submitted to the Plan for February 1, 2021, to March 1, 2021. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
This claim was submitted with all days of service in error. The claim to the Plan should not have included the date of service January 31, 2021, as that date of service should have been submitted separately to Original Medicare. Therefore, the Plan is not required to pay this claim as billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 3, 2022. 
 You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from May 26, 2021, to June 24, 2021.
You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says because only a portion of the claim can be paid by the Plan, the provider must bill Original Medicare for May 26, 2021, to May 31, 2021, and must bill the Plan for June 1, 2021, to June 24, 2021. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria.
The Plan is correct in this case. 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. However, the Plan cannot split claims for hospice care.
The enrollee was under the Medicare hospice benefit for dates of service May 26, 2021, to May 31, 2021. Therefore, two separate claims should have been submitted. One claim to Original Medicare for May 26, 2021, to May 31, 2021, and one claim to the Plan for June 1, 2021, to June 24, 2021. Therefore, we decided that the Plan does not have to pay this claim as billed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that at the time of the appeal a PET scan was medically necessary for the initial treatment of prostate cancer. The Plan denied your request. The Plan says that Medicare does not cover PET scans for this purpose. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that PET scans are not covered for the initial staging of prostate cancer. This PET scan was requested for that purpose. Therefore, we decided that the Plan does not have to provide coverage for the PET scan requested for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for skilled nursing facility (SNF) services provided from August 1, 2021, to August 16, 2021.
You asked the Plan to waive this cost share. You say that no one told you there would be a copayment for these extended services. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial for insufficient information in the case file regarding your stay. The Plan requested a reopen and provided additional information.
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 that you must pay $178 per day for days 21-100 of a SNF stay.
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 copayments charged for skilled nursing facility (SNF) services provided from August 1, 2021, to August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services (D0274) provided from October 19, 2021, to November 8, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says your benefit for code D0274 had already been exhausted. Maximus overturned the Plans denial stating insufficient claim information had been submitted showing this benefit was previously paid. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provided documentation to show this benefit was exhausted between February 1, 2021, and February 28, 2021. Therefore, we decided that the Plan does not have to pay for dental services (D0274) provided from October 19, 2021, to November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided 
on March 20, 2021, March 22, 2021, and March 24, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation shows 
that one unit of this code was supported. There is no additional documentation that indicate additional units. 
Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services 
have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
services coded 99233 provided on March 20, 2021, March 22, 2021, and March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that two holes were filled in your tooth, and they did 
not hold. 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 Plan's 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 March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) and a panoramic x-ray 
(D0330) provided on January 27, 2022. 
 
You asked the Plan to pay for x-rays. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says periapical x-rays (D0220, D0230) and a panoramic x-ray (D0330) are not 
covered by 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 periapical 
x-rays (D0220, D0230) and a panoramic x-ray (D0330) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) provided on March 
15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this service should be covered in full. 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 a limited oral evaluation (D0140) provided 
on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
dental work. 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 August 24, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5214) provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the dentist told you this service would not 
be covered. 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 May 6, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second denture reline (D5751) provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were not made aware of this information. 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 Plan's 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 April 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a second denture reline (D5751) provided on April 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (code 97026) provided from November 4, 
2021, to November 9, 2021. 
 
You asked the Plan to pay for the infrared therapy. You say that this patient has both Medicare Parts A and B, 
so this should be covered. The Plan denied your request. The Plan says infrared therapy is not covered. The 
Plan must follow Medicare rules. Medicare rules say that infrared therapy is non-covered for all indications. 
Therefore, we decided that the Plan does not have to pay for infrared therapy (code 97026) provided from 
November 4, 2021, to November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that the dentures did not fit properly. You say 
that you would like the Plan to handle this issue. 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 May 10, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider told you that you would not be 
responsible for the cost of the services. The Plan denied your request. The Plan says your benefit for the 
requested 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 your benefit for the requested services was exhausted on date of service June 21, 2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental consultation (code D9310) you received on April 
11, 2022. 
 
You asked the Plan to pay for the dental consultation (code D9310). You say that you believe your Plan should 
cover this service. The Plan denied your request. The Plan says this service is not covered under 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. The Plan's dental benefit 
includes coverage only for those dental services specifically listed in your dental benefit chart.  Code D9310 is 
not listed as a covered dental service. 
 
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 the dental 
consultation (code D9310) you received on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar tooth on March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for endodontic therapy, molar tooth on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided May 9, 2022. 
 
You asked the Plan to pay for the diagnostic dental consultation. You say that your dentist referred you to have 
this service. The Plan denied your request. The Plan says this service is not covered under your 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 the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010), bone replacement graft for ridge preservation - per site (D7953), and guided tissue regeneration - 
resorbable barrier, per site (D4266). 
 
You asked the Plan to pay for an endosteal implant, bone replacement graft and guided tissue regeneration. 
You say that you would like these services covered. The Plan denied your request. The Plan says these services 
are not covered under your 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 surgical 
placement of implant body: endosteal implant (D6010), bone replacement graft for ridge preservation - per site 
(D7953), and guided tissue regeneration - resorbable barrier, per site (D4266).