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

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), bone replacement graft for ridge preservation - per site (D7953), surgical 
placement of implant body: endosteal implant (D6010) and deep sedation/general anesthesia  first 15 minutes 
(D9222) provided July 15, 2021. 
 
You asked the Plan to pay for the extraction, bone replacement graft, endosteal implants and deep 
sedation/general anesthesia. You say that the services were provided for medical reasons. The Plan denied your 
request. The Plan says you have exhausted 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 covers the extraction, 
bone replacement graft, endosteal implants and deep sedation/general anesthesia up to $1,000 every year.  
We looked at the file and Medicare rules. The Plan provided documentation showing that the remaining $264 
in your dental allowance was applied to anesthesia provided on the same date of service, July 15, 2021. You 
have been asked to pay the remaining amount above the $1,000 dental allowance. These services are not 
eligible for coverage under your medical benefit. Therefore, we decided that the Plan does not have to pay for 
the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), bone replacement 
graft for ridge preservation - per site (D7953), surgical placement of implant body: endosteal implant (D6010) 
and deep sedation/general anesthesia  first 15 minutes (D9222) provided July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for hearing aids provided on  
March 8, 2022. 
 
You asked the Plan to pay an additional amount for hearing aids. The Plan denied your request. The Plan says 
the Plan has paid the maximum benefit amount of $3,000.00. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum hearing aid 
benefit amount of $3,000.00. Therefore, we decided that the Plan does not have to pay an additional amount for 
hearing aids provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 31, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were unaware that the new treating 
provider did not receive the images that you requested from the old provider. 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 February 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 
31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82728, 83540, 83550) provided on 
January 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that there is no agreement in place to include these 
services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
 
 We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82728, 83540, 
83550) provided on January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopy provided on March 1, 2022. 
 
You asked the Plan to pay for fluoroscopy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because code 76000 is 
considered inclusive to other services and separate payment is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, code 76000 should not be separately reported with spinal procedures, and the record does 
not support that this procedure was separate and distinct from the other services covered by the Plan. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for fluoroscopy provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $1,000 more for the complete mandibular denture (D5120) provided on 
August 27, 2021. 
 
You asked the Plan to pay $1,000 more for the complete mandibular denture. You say that the Plan says told 
you that you had to pay for services rendered by an out-of-network provider, and you would be reimbursed. 
The Plan denied your request. The Plan says that you received this denture from an out-of-network provider, 
and the Plan paid $575. 
 
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 the file and Medicare rules. The record shows that you received a new denture because your 
previous denture was more than five years old. The contract says that comprehensive dental benefits cannot 
exceed $3,000 every year. Although the Plan does not normally pay for out-of-network dental services, the 
Plan reimbursed you $575 for this denture. The documentation does not show evidence that your $3,000 
allowance for comprehensive dental services has been exhausted. The Evidence of Coverage does not state that 
only the allowed amount for an out-of-network covered dental service will be paid. You also say that you were 
told by a Plan representative that if you received services from an out-of-network provider, you would have to 
pay up front, and would be reimbursed by the Plan. Based on this information, we decided that the Plan's rules 
for coverage of the complete mandibular denture have been met. Therefore, we decided that the Plan has to pay 
$1,000 more for the complete mandibular denture (D5120) provided on August 27, 2021.  
 
Please Note: The Plan spoke with the providers office who confirmed that it took five visits to complete the 
dentures, but you were only billed once for them on August 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided April 6, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that the first dentist did a bad job. 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 
limited oral evaluation - problem focused (D0140) provided April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 68801 provided on August 27, 2021. 
 
You asked the Plan to pay for procedure code 68801. You say that modifier 59 was added to indicate a distinct 
procedural service. You say that the medical records should be reviewed, and the claim reconsidered for 
payment. The Plan denied your request. The Plan says procedure codes 68761 and 92014 have been 
overturned. The Plan also says procedure code 68801 is inclusive to 68761 and cannot be separately 
reimbursed. 
 
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 68801 is a column II code to column I code 68761; however, 68801 
was billed with a modifier.  
 
We asked our coder 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 procedure code 68801. Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes bilateral dilation of lacrimal punctum and closure of lacrimal punctum. In this case, 
68801 should not be coded in addition to plug closure. Dilation is a necessary part of the procedure to implant 
the plugs and is integral to the performance of plug closure. The smaller procedure is integral to the larger 
procedure and would not be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 68801 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 68801 provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a shoulder orthosis provided on April 6, 
2022. 
 
You asked the Plan to waive the coinsurance for a shoulder orthosis. You say that you should not have to pay 
this coinsurance amount, because you already have a sling. The Plan denied your request. The Plan says the 
coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $125.87 resulting in a 
coinsurance amount of $25.17 ($125.87 x 20% = $25.17) 
 
You have been asked to pay a $25.17 coinsurance for a shoulder orthosis. a shoulder orthosis falls within the 
Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a shoulder orthosis provided on April 6, 2022.  Your complaint about your wife not being able to accompany you to your appointment with your sling, is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 12, 2021, billed with 
codes 81222, 81223, 81403, 81405, 81406, and 81407. 
 
You asked the Plan to pay for genetic testing. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 12, 
2021, billed with codes 81222, 81223, 81403, 81405, 81406, and 81407.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for a colonoscopy with biopsy and tissue 
exam provided on March 19, 2022. 
 
You asked the Plan to reduce the cost sharing for the colonoscopy with tissue exam. You say that you had other 
claims processed on the same date of service at the same facility at the in-network rate. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out of network diagnostic procedures and lab services.  
 
You have been asked to pay $364.13 which is 40% of the allowed amount for a colonoscopy with tissue exam.  Date of Service Code Allowed Amount Coinsurance 
March 19, 2022 45380 $499.84 $199.94 
March 19, 2022 43239 $195.02 $78.01 
March 19, 2022 88305 $215.46 $86.18 
    
Grand Total   $364.13 
 
The colonoscopy and tissue exam both fall within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies 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 reduce the cost sharing for a colonoscopy with 
biopsy and tissue exam provided on March 19, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional three home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional three physical therapy visits. You say that the enrollee 
remains in need of physical therapy services for her injury. The Plan denied your request. The Plan says that 
the enrollee's level of function is now at the level that no further therapy is required in the home health setting. 
 
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. Review of the file shows that the Plan did not forward any medical records 
directly from the home health agency. This appeal was requested by the primary care physician who would not 
be responsible for providing home health records with the appeal. The file also shows that the Plan's Utilization 
Management (UM) department was doing concurrent reviews along the course of this home health episode. 
This would indicate that the Plan had access to these medical records and yet failed to forward them to 
Maximus. For this reason, we cannot confirm whether the coverage criteria were met in this case. Therefore, 
we decided that the Plan has to pre-approve an additional three home health physical therapy visits.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on March 1, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-
rays. You say that you want a refund from the first treating provider. 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 January 19, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service December 6, 2021. 
 
You asked the Plan to pay for procedure code S0020. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for date of service December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual swingaway for a wheelchair (E1028). 
 
You asked the Plan to pre-approve a manual swingaway. You say that the requested wheelchair feature is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested feature have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a covered indication for swingaway, retractable, 
or removable hardware (E1028) would be to move the component out of the way so that the enrollee can 
perform a slide transfer to a chair or bed. 
 
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 manual swingaway. Our reviewer 
says that the requested feature is not medically reasonable and necessary in this case. Our physician reviewer 
found that accessories that are swingaway, retractable or removable hardware are considered appropriate when 
the component or accessory needs to be moved out of the way so that the enrollee can perform a slide transfer 
to a chair or bed. In this case, the enrollee has a neurologic disorder with functional deficits. The enrollee is 
able to use a stand-pivot transfer. The enrollee does not require the requested feature to perform a slide transfer 
to a chair or bed.  
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 manual swingaway have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual swingaway for a wheelchair (E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210), provided by a participating provider on January 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 September 4, 2019. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral imaging (D0210), provided by a participating provider on January 11, 2022.