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

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and tobacco counseling (D1320) provided on September 9, 2021.

You asked the Plan to pay for the dental services. You say that you were told on multiple visits that the services were covered. The Plan denied your request. The Plan says the dental services were received from an out-of-network provider and are not covered by your supplemental benefits. The Plan also says that tobacco counseling (D1320) is not covered by the Plan's supplement 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.

The record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and tobacco counseling (D1320) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300) and electronic 
connection between wheelchair controller and two or more power seating system motors (E2311).
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the medical records provided 
support the necessity of the requested services. The Plan denied your request. The Plan says the wheelchair 
power seat elevation system coded as E2300 and E2311 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve power seat elevation system (E2300) and 
electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on October 6, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. 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 payable to this 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, a Mental Health Counselor is not eligible for 
Medicare payment. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90837) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on February 11, 2022. You asked the Plan to pay for the testing services. You say that the testing is a covered benefit. The Plan denied 
your request. The Plan says screening services without a valid medical diagnosis are not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee was experiencing 
persistent or elevated cancer-risk factors. The records do not show the enrollee is being considered for a repeat 
biopsy due to these risk factors. Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ConfirmMDx testing provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on August 
19, 2021. 
 
You asked the Plan to pay for code 99285. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the emergency department visit 
(99285) provided on August 19, 2021, have been met. . Therefore, we decided that the Plan does not have to 
pay for the emergency department visit (99285) provided on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for antibacterial irrigation (D9630) and a preventive procedure 
(D1999) provided on April 11, 2022. 
 
You asked the Plan to pay for antibacterial irrigation and a preventive procedure. You say that you were 
advised that deep cleanings were covered. The Plan denied your request. The Plan says antibacterial irrigation 
(D9630) and a preventive procedure (D1999) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
antibacterial irrigation (D9630) and a preventive procedure (D1999) provided on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Betadine or phisohex solution (A4246), the Gloves 
(A4930), and the Skin sealants (A6250) provided on January 24, 2022. 
 
You asked the Plan to pay for codes A4246, A4930, and A6250. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Medicare says that unconditionally packaged services are identified 
in the OPPS Addendum B with status indicator of N and these services are not paid separately since payment is 
included in the APC. Codes A4246, A4930, and A6250 are identified with a status indicator of N. Therefore, 
we decided that the Plan does not have to pay for the Betadine or phisohex solution (A4246), the Gloves 
(A4930), and the Skin sealants (A6250) provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your 
diagnostic testing is currently stable. 
 
The Plan must follow Medicare rules. The rules say that oxygen supplies are only covered under certain 
medical indications.  
 
We looked at the file, and Medicare rules. The file shows that your oxygen saturation level is above 90%. 
Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dentist did not tell you about the term for the 
procedure. You say that you were surprised to find out that the service was not covered. The Plan denied your 
request. The Plan says protective restoration 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the protective restoration is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the protective 
restoration (D2940) provided on April 27, 2022.
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), gingival irrigation  per quadrant (D4921), and 
unspecified preventive procedure, by report (D1999) provided March 28, 2022. 
 
You asked the Plan to pay for the limited oral exam, periapical x-ray, gingival irrigation and unspecified 
preventative procedure. You say that you cannot afford the cost of these services. The Plan denied your 
request. The Plan says you have exceeded the frequency limits for the limited exam and x-rays. The gingival 
irrigation and unspecified preventative procedure are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam and periapical x-ray once per calendar year.  
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited exam and 
periapical x-ray were previously covered on March 8, 2022. Based on this information, we decided that the 
Plan's frequency limit for coverage of the limited oral exam and periapical x-ray has been exceeded. Though 
the Plan offers dental benefits in excess of Medicare coverage, the gingival irrigation and unspecified 
preventative procedure are not among those covered services. 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), gingival irrigation  per quadrant (D4921), and unspecified preventive procedure, by report 
(D1999) provided March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim reprocessed for payment. 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 February 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
February 13, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you feel you should not have 
been discharged from your initial hospital stay. You say that you have already paid $990 for the initial hospital 
stay. You also say that you feel you should not be responsible for this copayment. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 $330 
copayment per day for days 1 to 5 for Inpatient hospital care.  
 You have been asked to pay a $330 copayment per day for days 1 to 5 for the inpatient care. The inpatient care 
falls within the Inpatient hospital care 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 copayment for 
the inpatient hospital care provided from February 13, 2022, to February 16, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on January 12, 2022. 
 
You asked the Plan to pay for an evaluation. You say that the provider told you this was an authorized covered 
benefit. The Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not 
covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on February 17, 
2022, and a partial denture retainer (D6740 x2) and a partial denture pontic (D6245) provided on March 2, 2022. 
 
You asked the Plan to pay for the x-rays, a retainer, and a pontic. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says periapical x-rays (D0220, D0230), partial denture 
retainer (D6740 x2), and partial denture pontic (D6245) are not covered by your dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periapical x-rays (D0220, D0230), 
partial denture retainer (D6740 x2), and partial denture pontic (D6245) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) 
provided on February 17, 2022, and a partial denture retainer (D6740 x2) and a partial denture pontic (D6245) 
provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an osseous surgery 
(D4260), and periodontal scaling and root planing (D4341), provided by an out-of-network provider on June 
15, 2021, to November 3, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, an osseous surgery, and periodontal scaling and root 
planing. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the 
rendered 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 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 a 
limited oral evaluation (D0140), an osseous surgery (D4260), and periodontal scaling and root planing (D4341), 
provided by an out-of-network provider on June 15, 2021, to November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four bioimpedance spectroscopy (BIS) (93702 x4). 
 
You asked the Plan to pre-approve the BIS services. You say that you would like this necessary procedure to be 
authorized. The Plan denied your request. The Plan says BIS is considered experimental and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 BIS services. Our reviewer says that 
the requested BIS services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has intraductal breast cancer. The records indicate that the 
enrollee does not have evidence of edema, nor has she had, or has planned, operative intervention. Our 
reviewer found that there is insufficient literature to establish the requested test as safe and effective, as defined 
by Medicare rules, for the enrollee's specific clinical condition. 
 
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 BIS services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve four bioimpedance spectroscopy (BIS) (93702 x4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81406, 81162, and 81479) provided 
on January 7, 2022. 
 
You asked the Plan to pay for codes 81406, 81162, and 81479. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479 only. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (81406, 81162, and 81479) provided on January 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 5, 2022, to February 28, 2022. 
 
You asked the Plan to pay for the SNF care provided from February 5, 2022, to February 28, 2022. You say 
that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the 
enrollee was no longer receiving daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 pay for the SNF care provided from February 5, 
2022, to February 28, 2022. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF 
care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 
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 the SNF care provided from February 5, 2022, to February 28, 2022, have not 
been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from February 5, 2022, to February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and periapical x-rays (D0220, 
D0230) provided on September 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why your dental claim 
was denied. 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 a panoramic x-ray was exhausted on date of service December 4, 2020. The record also 
shows your benefit for periapical x-rays was exhausted on date of service January 19, 2021. Therefore, we 
decided that the Plan does not have to pay for a panoramic x-ray (D0330) and periapical x-rays (D0220, 
D0230) provided on September 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.