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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
comprehensive oral evaluation (D0150), and bitewing x-rays (D0274) provided on August 16, 2021, and 
September 7, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, comprehensive oral evaluation, and 
bitewing x-rays. You say that you were not advised that these exams would not be covered. You also say that 
you are on disability and do not receive that much to pay the bills you have been sent. The Plan denied your 
request. The Plan says these services exceed the maximum allowed per period. 
 
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, problem focused limited oral 
evaluation (D0140) and bitewing x-rays (codes D0270, D0272, D0273, D0274, and D0277) are each limited to 
one procedure per plan year. The record shows that you received a problem focused limited oral evaluation 
(D0140) on September 9, 2021, and bitewing x-rays (D0274) on August 26, 2021, and your problem focused 
limited oral evaluation (D0140) and bitewing x-rays (D0274) benefits have been exhausted. The Plan contract 
also says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The 
record shows that you received a comprehensive oral evaluation (D0150) on February 27, 2020 and your 
comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation 
(D0150), and bitewing x-rays (D0274) provided on August 16, 2021, and September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays 
(D0274), topical applications of fluoride varnish (D1206), and periodontal maintenances (D4910) provided on 
January 19, 2021, and June 22, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluations, bitewing x-rays, topical applications of fluoride 
varnish, and periodontal maintenances. You say that you would like to be reimbursed for the dental coverage 
that you are entitled to. The Plan denied your request. The Plan says you received these services from a 
provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of 
Medicare effective March 15, 2015, to March 15, 2023. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), topical 
applications of fluoride varnish (D1206), and periodontal maintenances (D4910) provided on January 19, 2021, 
and June 22, 2021 by a Medicare opt out provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Keytruda for the enrollee.
You asked the Plan to provide coverage for Keytruda. You say that Keytruda is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda
(Pembrolizumab). Our Physician Reviewer determined while Keytruda is not FDA-approved for the
enrollee's diagnosis, the use of Keytruda is supported by one of the major drug compendia or by clinical
research that appears in a Centers for Medicare & Medicaid Services approved medical journal. The Plan
requested a reopen and argues there is no established evidence to support the use of single-agent therapy with
Keytruda (pembrolizumab) for metastatic esophageal adenocarcinoma that is MSS-stable, MMR proficient, and
TMB-low. Our Medical Director has concluded the Plan is correct in this case. The medical records show the
enrollee is a 60-year-old woman with invasive poorly differentiated adenocarcinoma of the esophagus, which is
metastatic to lymph nodes, liver, and bone. The adenocarcinoma is PDL1 positive. There is insufficient support
for the use of Keytruda for the treatment of the enrollee's metastatic adenocarcinoma of the esophagus.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to provide coverage for Keytruda for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for SNF services. You say that SNF admission is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the
Plans denial. The Plan requested a reopen and stated wedid not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
Our Physician Reviewer you had not yet reached your maximum level of function and SNF services
were appropriate. The Plan requested a reopen and argues the medical records show you were not able to
adequately participate in and benefit from skilled therapy, as your pain was noted to be 10/10 and you were
unable to walk or bear weight. The records who you were unable to do more than sit at the edge of the bed
and stated to be unstable for discharge due to uncontrolled pain.
The plan is correct in this case. The documentation does not support that it was medically reasonable and
necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing
facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to provide coverage for skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns - porcelain fused to high noble metal 
(D6750) and pontic - porcelain fused to high noble metal (D6240). 
 
You asked the Plan to pre-approve retainer crowns and pontic. You say that you would like 2 additional crowns 
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 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 pre-approve 
retainer crowns - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal 
(D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic 
image (D0230) provided October 7, 2021. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-rays. You say that you don't feel you are 
responsible for any cost for these services. The Plan denied your request. The Plan says these services are not 
covered under your benefits. Additionally, the Plan has indicated that they contacted the provider who stated 
that your responsibility for this date of service is $0. 
 
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 
limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and 
intraoral - periapical each additional radiographic image (D0230) provided October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for proton beam therapy for the treatment of
prostate cancer for the enrollee.

You asked the Plan to provide coverage for proton beam therapy. You say that this treatment is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for proton beam
therapy for the treatment of prostate cancer. The Maximus Physician Reviewer determined that the theoretical
advantage of proton beam radiotherapy (RT) is in its dose distribution. Proton beam therapy thus permits the
delivery of high doses of RT to the target volume while limiting the "scatter" dose received by surrounding
tissues. Use of proton beam RT is expanding as more proton beam treatment centers open. However, there are
no randomized trials comparing proton beam therapy with photon therapy or brachytherapy in men with
clinically localized prostate cancer. A systematic review of the available evidence from American Society for
Radiation Oncology (ASTRO) on efficacy and toxicity concluded that outcomes were similar with proton beam
therapy and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for
the proton beam approach. The National Comprehensive Cancer Network (NCCN) Panel believes no clear
evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or longterm
toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to
x-ray-based regimens at clinics with appropriate technology, physics, and clinical expertise.

This patient has high risk prostate cancer with a Gleason score of 7. He suffered from recurrent urinary tract
infections after transurethral resection of the prostate, which indicates that brachytherapy would not be
appropriate treatment in this case. As such, the use of proton beam therapy is reasonable and medically
necessary.

The Plan requested a re-opening, citing an error on the face of the evidence. The Plan argues that there is no
applicability for this treatment other than use within a clinical trial.

Our Medical Director has concluded that the Plan is correct in this case. The enrollee is a 77-year-old man with
a diagnosis of acinar adenocarcinoma of the prostate, Gleason score 7 and does not meet the criteria for
Medicare coverage of proton beam therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan
does not have to provide coverage for proton beam therapy for the treatment of prostate cancer for the
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 30, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
30, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 30, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond March 30, 2022, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 30, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 
2022, forward.
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 September 13, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you were not advised that these services would not be covered by your insurance. You also say that if 
you had known, you would not have received these services. The Plan denied your request. The Plan says these 
services exceed the maximum counts allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) on February 27, 2020 and 
complete series of intraoral x-rays (D0210) on September 4, 2019 and your comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. 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 September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on November 4, 2021. 
 
You asked the Plan to pay for the scaling. You say that you needed this treatment and would like help paying 
for the cost of this service. The Plan denied your request. The Plan says this service is not covered under the 
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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 22, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you would like the Plan to cover the additional 
cleaning because a car accident has left you in need of frequent dentist appointments. The Plan denied your 
request. The Plan says this service does not meet the frequency requirements of the 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, prophylaxes (D1110) are limited to 
two procedures per plan year. The record shows that you received prophylaxes (D1110) on February 4, 2021, 
and June 10, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis (D1110) provided on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer tubing (A7010), and an oxygen concentrator 
(E1390) provided from July 30, 2021, to September 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nebulizer tubing (A7010), and an oxygen concentrator. You say that you are 
required to have oxygen 24/7, you were out of town, and you need to use a concentrator while at home. You 
also say you were able to take your concentrator with you, but it did break at one point, and you had to rent 
another one in the meantime until another one was sent to you. You also say that the home you were staying in 
was a two story home and you needed an extra concentrator for both floors since you cannot lift the 
concentrator up and down the stairs, and the Plan provider would not supply two concentrators at one time. The 
Plan denied your request. The Plan says an exchange to the concentrator was requested and delivered on July 1, 
2021, and the Plan does not provide duplicate or back-up equipment. The Plan also says that they will not reimburse for the additional oxygen concentrator rental with the purpose of having a device upstairs and 
downstairs within the home from this provider. The Plan also says this provider is not in the Plan, and the only 
exceptions are emergencies, urgently needed care, when the network is not available, out-of-area dialysis 
services, and cases in which the Plan authorized use of out-of-network providers. 
 
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 nebulizer tubing (A7010), and an oxygen 
concentrator (E1390) provided from July 30, 2021, to September 14, 2021, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 6, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim has not been billed correctly 
based on the services that were rendered. 
 
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 the genetic testing CPT codes billed (81227, 81230, 81240, 81241, 81355, 81479, 81291) are not 
supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 
81479. Based on this information, we decided that Medicare rules for coverage of the genetic testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services 
provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the benefit limit maximum 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. The Plan covers dental 
services when the services up to a maximum amount of $1,000.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have already been met. Therefore, we decided that the Plan does not have to pre-
approve dental services to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical additional radiographic image (D0230) provided 
by a participating provider on November 11, 2021. 
 
You asked the Plan to pay for periapical additional radiographic image. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the benefit limit for periapical radiographic imaging 
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. The Plan covers one periapical 
additional radiographic image per year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that more than one periapical 
radiographic images was provided on November 11, 2021. Based on this information, we decided that the Plan's rules for coverage of periapical additional radiographic image have already been met. Therefore, we decided that the Plan does not have to pay for periapical additional radiographic image (D0230) provided by a participating provider on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on February 16, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on February 16, 2021.