Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance response with no transport provided on May 28, 2021.
You asked the Plan to pay for ambulance response with no transport, to include the supplies. You say that this
bill should be paid by the Plan. You say that your wife called 911 because you passed out. You stated you were
told this would be covered. The Plan denied your request. The Plan says ambulance response with no transport
is not covered. Maximus partially overturned the Plans denial stating you should be held harmless for the
supplies as they are not separately billable. The Plan requested a reopen and stated that the cost of the supplies
would be covered if claim for the transport was covered. However, since no transport occurred, the provider is
within their right to bill you accordingly as response with no transport is not covered under Medicare
guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not pay
for ambulance services when there is no transport. This would include any supplies provided. The records show
the ambulance company did not provide transport services on May 28, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response with no transport provided on
May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH 
level of care is not medically necessary at this time. 
 
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 the documentation does not support that the enrollee requires services at the LTACH 
that are not available at the acute care hospital where he is currently receiving 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation (D9222, D9223 x 2) and therapeutic 
parenteral drug (D9610) provided on August 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says deep sedation services are not listed as covered. The Plan says that 
therapeutic parenteral drug 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 deep sedation services and 
therapeutic parenteral drug are not among those covered under this benefit. Additionally, 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 the deep sedation (D9222, D9223 x 2) and 
therapeutic parenteral drug (D9610) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay a 50% coinsurance for the crown (D2740) for tooth #29. We decided that 
the Plan does not have to pay more for the crown (D2740) for tooth #28 and prefabricated post and core in 
addition to crown (D2954) for tooth #28.  
 
You asked the Plan to pay more for the crowns (D2740) for tooth #'s 28 and 29 and prefabricated post and core 
in addition to crown (D2954) for tooth #28 provided on October 19, 2021. You say that you paid for this 
service in full on the date of service and your allowed amount has not been used up. You also say that you were 
assured a share would be covered. The Plan says that this claim processed and paid correctly. 
 
We decided that the Plan has to pay a 50% coinsurance for the crown (D2740) for tooth #29.  
 
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. The Plan did not provide a copy of the applicable x-rays for this case. Without 
this information we cannot determine that the Plan's coverage rules support the denial of payment. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay a 50% coinsurance for the crown (D2740) for tooth #29.  
 
We also decided that the Plan does not have to pay more for the crown (D2740) for tooth #28 and 
prefabricated post and core in addition to crown (D2954) for tooth #28. 
 
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, you are responsible for a 50% 
coinsurance for Major Restorative services including crowns. Therefore, we decided that the Plan does not 
have to pay more for the crown (D2740) for tooth #28 and prefabricated post and core in addition to crown 
(D2954) for tooth #28. 
 
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 bitewing x-rays (D0272) provided on January 6, 2022. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you did not receive x-rays on this date of 
service. The Plan denied your request. The Plan says this service is allowed two times per calendar year. The 
Plan also says that you have reached this limit for this 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, you are limited to 2 of either codes 
D0220, D0230, D0270, D0272, D0273, or D0274 per 1 calendar year. The record shows that you received a 
first intraoral periapical x-ray (D0220) and an additional intraoral periapical x-ray (D0230) on January 6, 2022 
and this benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing 
x-rays (D0272) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2332) and surgical extractions 
(D7210) provided on December 2, 2021. 
 
You asked the Plan to pay for the resin-based composite and surgical extractions. You say that your teeth 
needed to be extracted and you do not have the resources to pay the dentist. The Plan denied your request. The 
Plan says you have exceeded the limits set in the subscriber agreement. The Plan also says that the $2,500 
benefit maximum was met during the processing of this service. 
 
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 Plan offers a $2,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the December 2, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2332) and surgical extractions (D7210) provided on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87500) provided on April 6, 2021. 
 
You asked the Plan to pay for code 87500. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 code 87500 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 the laboratory services (87500) provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified oral surgery procedure (D7999) provided on 
October 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that the procedure was performed to stop bleeding. 
You also say that it was medically necessary. The Plan denied your request. The Plan says the unspecified oral 
surgery procedure is not listed as 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 unspecified oral surgery procedure 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified oral surgery procedure (D7999) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260), two free soft tissue graft 
procedures (D4277 x2), and three intravenous moderate (conscious) sedation/analgesia services (D9243 x3) 
provided on November 16, 2021. 
 
You asked the Plan to pay for the osseous surgery, free soft tissue graft procedures, and intravenous moderate 
(conscious) sedation/analgesia services. You say that you would like a portion of these services to be covered. 
The Plan denied your request. The Plan says these services are not covered expenses under your plan. The Plan 
also says that when you contacted the Plan on November 12, 2021 you were advised that these services were 
not covered under your plan. 
 
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 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 
osseous surgery (D4260), two free soft tissue graft procedures (D4277 x2), and three intravenous moderate 
(conscious) sedation/analgesia services (D9243 x3) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride varnish you received from a 
dentist on December 8, 2021. 
 
You asked the Plan to pay for the application of fluoride varnish. You say that this dentist is in-network so this 
claim should be paid. The Plan denied your request. The Plan says it has reprocessed your dental claim and has 
paid for the services except for the application of fluoride varnish.  The Plan says that this service is 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. This benefit includes coverage 
only for those dental services listed in your Optional Supplemental Dental Coverage chart. The chart does not 
list the application of fluoride varnish 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 
application of fluoride varnish you received from a dentist on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the liposuction to the lip (14061, 15771). 
 
You asked the Plan to pre-approve the liposuction to the lip. You say that the service is medically necessary. 
The Plan denied your request. The Plan says te notes submitted do not indicate that your lip was causing you to 
difficulty with swallowing, eating, or breathing. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 liposuction to the lip. Our reviewer 
says that  Our reviewer found  
 
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 liposuction to the lip have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the liposuction to the lip (14061, 15771).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a trilogy home ventilator (E0466).
You asked the Plan to provide coverage for a trilogy home ventilator (E0466). You say that this claim should
be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a trilogy home
ventilator (E0466). The Maximus Physician Reviewer determined, "The denial of the ventilator is upheld.
However, the ventilator should be covered for 3 months to provide time for transition to BiPAP."
The Plan requested a reopen and argued the only transition period Medicare requires are covered services when
a person transitions from one plan to another. The Plan states they should not have to provide payment to
facilitate a 3-month transition from E0466-non-invasive ventilator to E0471-respiratory assist device with
beck-up rate (AKA BiPAP). The Plan noted that the E0471-BiPAP with back-up rate was previously approved.
The Plan is correct in this case. The medical records show a diagnosis of end-stage COPD, and recurrent
episodes of hypoxic and hyper carbic respiratory failure. The records show the enrollee has been on a Trilogy
ventilator for over a year, with no further episodes of hospitalization or acute respiratory failure. Rather than a
partially favorable determination, a full denial would have been appropriate in this case. 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 trilogy home ventilator (E0466) have not been met. Therefore, we decided
that the Plan does not have to provide coverage for a trilogy home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 copayment charged for vision services provided on
April 20, 2021.
You asked the Plan to waive these services. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this service was billed as a routine eye exam which does not count toward
the maximum out of pocket. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract language.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $35 copayment for routine eye exam. Your contract also states services marked
with an asterisk do not count toward the maximum out of pocket. This service was billed by the provider as a
routine eye exam, which does not count toward the maximum out of pocket per page 4-73 of the Plan contract.
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 $35 copayment charged for vision services provided on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.  Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0230 x 5), 2D photographic images 
(D0350 x 4), cone beam computed tomography (CT) (D0367), and fluoride varnish (D1206) provided on 
December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider performed unnecessary exams on 
you. You also say that you specifically asked for only a cleaning. The Plan denied your request. The Plan says 
1 periapical x-ray is covered per calendar year. The Plan also says that 2D photographic image, cone beam CT, 
and fluoride varnish are not listed as covered services. 
 
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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 1 periapical x-ray 
that you received on the ate of service in this case. Additionally, the 2D photographic image, cone beam CT, 
and fluoride varnish are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the periapical x-rays (D0230 x 5), 2D photographic images (D0350 x 4), cone beam 
computed tomography (CT) (D0367), and fluoride varnish (D1206) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 14, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan presented documentation to show that
this claim denied because the provider billed this service inappropriately. The Plan submitted specific
documentation of only 18 drug classes counted from the laboratory results received. The codes billed are only
used when 22 or more classes were tested. The Plan states there is a more appropriate code for the services
provided to the enrollee.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the Plan
submitted lab results to show less than 22 classes were tested. This claim was not coded appropriately.
Medicare uses another code for testing less than 22 classes of drugs. Therefore, we decided that the Plan does
not have to pay for drug testing provided to the enrollee on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on December 16, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral 
evaluation. You say that the initial exam and x-ray is an essential and routine part of a root canal procedure. 
You also say that it has nothing to do with your periodic preventive exams and should not be denied on the 
basis that you have exceeded your exams limit for the year. The Plan denied your request. The Plan says cone 
beam CT capture and interpretation is not a covered expense under your dental plan. The Plan also says that 
your benefits for the problem focused limited oral evaluation have been satisfied and the frequency limitation 
has been exceeded. 
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, cone beam CT capture and 
interpretation (D0364) is not among those covered under this benefit. The contract says that exams are limited 
to two procedure codes per calendar year. The record shows that you received periodic oral evaluations 
(D0120) on May 5, 2021, and November 16, 2021 and your exams benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on December 16, 2021.