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

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
November 11, 2021. 
 
You asked the Plan to pay 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 this service is 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the frames (V2020) and trifocal 
lenses (V2307, V2308) provided February 28, 2022. 
 You asked the Plan to provide additional payment for the eyeglass frames and trifocal lenses. You say that you 
haven't gotten glasses since 2008 and do not understand how your benefit is exhausted. The Plan denied your 
request. The Plan says your $150 allowance was applied to this purchase. No further payment is due. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $150 allowance every 24 months.  
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that the full $150 
allowance was applied towards your eyewear. You have been asked to pay the difference between the 
allowance and the total cost billed for the eyewear. This means you have been asked to play the correct amount 
according to your contract with the Plan. Therefore, we decided that the Plan does not have to provide 
additional payment for the frames (V2020) and trifocal lenses (V2307, V2308) provided February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic (D6245) for tooth #15, and a glass cap (D6740) 
for teeth #14 and #16 provided by a participating provider. 
 
You asked the Plan to pre-approve pontic and a glass cap. You say that the requested services are the best 
dental plan. The Plan denied your request. The Plan says the documentation provided does not demonstrate any 
specific need or condition that precludes the use of a removable prosthesis. 
 
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 covers pontic and a 
glass cap when the services are medically necessary and reasonable.  
 
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 pontic and a glass cap. Our reviewer 
says that this service is not medically necessary. Our physician reviewer found the amount of structural damage 
to teeth #14 or #16 appears to be minimal, however a replacement of tooth #15 is possible with a bridge.  It is a 
reasonable treatment option to place a bridge from teeth #14-16. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontic and a glass cap have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pontic (D6245) for tooth #15, and a glass cap (D6740) for teeth #14 and #16 
provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care management services provided on December 17, 2021, 
by an out-of-netwok provider. 
 
You asked the Plan to pay for the care management services. You say that since the enrollee was in a nursing 
home the provider was not responsible for getting authorization. The Plan denied your request. The Plan says 
an authorization was not obtained prior to the services being rendered and the provider is not participating with 
the enrollee's plan. 
 
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 care management services provided on December 
17, 2021, by an out-of-netwok provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you would like the claim paid because 
you thought the enrollee had Medicaid. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 a specialist office visit provided on December 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the x-rays provided on April 13, 2022. We also decided that the Plan 
does not have to pay for the tissue regeneration and imaging provided on April 13, 2022.  
 
You asked the Plan to pay for tissue regeneration, imaging, and x-rays. You say that you disagree with the 
denial of the dental services. The Plan says that tissue regeneration (D4265), cone beam imaging (D0367), and 
intraoral x-rays (D0210) are not covered by your dental benefits. 
 We decided that the Plan has to pay for the x-rays provided on April 13, 2022. 
 
According to the EOC, one set of dental x-rays are covered every one to three years. There is no evidence in 
the case file that this benefit has been previously exhausted. Therefore, we decided that the Plan has to pay for 
the intraoral x-rays (D0210) provided on April 13, 2022. 
 
We also decided that the Plan does not have to pay for the tissue regeneration and imaging provided on 
April 13, 2022. 
 
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, tissue regeneration (D4265) and cone 
beam imaging (D0367) are not covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the tissue regeneration (D4265) and cone beam imaging (D0367) provided on April 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 16, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene. 
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the consultation-diagnostic service rendered 
by a dentist or physician other than requesting dentist or physician (D9310) on February 9, 2022. 
 
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 this service is 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the consultation-diagnostic service rendered by a dentist or physician other than requesting dentist or physician 
(D9310) on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and the topical application of fluoride (D1208) provided on January 18, 2022. 
 
You asked the Plan to pay for an evaluation, prophylaxis, and fluoride. You say that you were unaware your 
dental benefits were inactive for the month of January 2022. The Plan denied your request. The Plan says these 
services are not covered by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for a periodic oral evaluation 
(D0120), prophylaxis (D1110), and the topical application of fluoride (D1208) provided on January 18, 2022.  
 
Maximus Federal Services read your letter and knows that you may have a question regarding your 
enrollment in the Plan. Maximus Federal Services cannot answer enrollment questions. Maximus Federal 
Services is sending a copy of your case file and your letter to the CMS Regional Office, so that it 
can look into your enrollment question.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from November 27, 2021 
to December 26, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that a RAP was not submitted for these claims. 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 home health services rendered from November 
27, 2021 to December 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete 
series of radiographic images (D0210) rendered by the out-of-network (OON) provider on April 16, 2021. 
 
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 the services are not payable as they were 
rendered by an out-of-network dental 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.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the services in this case were rendered by an  
out-of-network dental provider. The Plan contract states that dental services received by an out-of-network 
dentist are not covered.  
 Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the complete series of radiographic images (D0210) rendered by the out-of-network (OON) provider on  
April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the intraoral - complete series of radiographic images (D0210) 
provided August 2, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you had to wait hours for the x-rays 
and no further services were performed. The Plan denied your request. The Plan says that 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. The Plan covers the complete 
series of x-rays twice every year. 
 
We looked at the file and Medicare rules. The Plan contract states that dental x-rays are covered twice per year. 
The contract does not specify that there are specific x-rays that are covered and specific x-rays that are not 
covered. The Plan has provided no evidence that the two x-ray limit has been exceeded. Based on this 
information, we decided that the Plan's rules for coverage of the complete series of x-rays have been met. 
Therefore, we decided that the Plan has to pay for the intraoral - complete series of radiographic images 
(D0210) provided August 2, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
You say that the enrollee needs 24-hour care and that the requested IRF is the most appropriate fit for the 
enrollee to be acknowledged and cared for properly. The Plan denied your request. The Plan says the records 
do not show that the enrollee needs to be seen by a rehabilitation doctor 3 times a week. The Plan says that the 
records do not show that the enrollee can yet tolerate or need 3 hours of therapy a day, 5 days a week. The Plan 
says that the enrollee does not need an intensive team for care. The Plan says that the enrollee can safely 
receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for back surgery and was transferred to skilled nursing on June 28, 2022. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2022. 
 
You asked the Plan to pay for an office visit. You say to please review records and referral for ortho services. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 an office visit provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denied service. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 the laboratory services provided on January 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (93306), transcatheter 
placement of intravascular stent(s) (37215), and selective catheter placement (36222) provided on May 10, 
2019, and May 14, 2019. 
 
You asked the Plan to pay for the transthoracic echocardiography, transcatheter placement of intravascular 
stent(s), and selective catheter placement. You say that four claims were initially sent timely, but only one 
claim was paid for. You also say that you would like these claims to be processed and paid, as they were sent at 
the same time. The Plan denied your request. The Plan says your claim has been denied correctly by the health 
Plan due to untimely submission of the initial claim. The Plan also says that no valid proof of timely filing has 
been submitted. 
 
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 transthoracic echocardiography, transcatheter placement of intravascular 
stent(s), and selective catheter placement was not filed until February 10, 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 transthoracic echocardiography (93306), transcatheter placement of intravascular 
stent(s) (37215), and selective catheter placement (36222) provided on May 10, 2019, and May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), an implant supported 
crown (D6065), and prefabricated abutment (D6056), provided by a participating provider. 
 
You asked the Plan to pre-approve an endosteal implant, an implant supported crown, and prefabricated 
abutment. You say that these services are medically necessary. The Plan denied your request. The Plan says the 
requested dental services 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 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 
endosteal implant (D6010), an implant supported crown (D6065), and prefabricated abutment (D6056), 
provided by a participating provider.