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

 
We decided that the Plan has to pay for the crown (D2740) and core buildup, including any pins when required 
(D2950) provided on February 18, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you would like to be reimbursed for 
these services. The Plan denied your request. The Plan says that these procedures are not benefits under the 
dental plan. 
 
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 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the crown (D2740) and core buildup, including any pins when required (D2950) 
provided on February 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the filling (D2335) for tooth # 11 provided on January 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that your tooth came off. You say that you feel this 
should be covered. The Plan denied your request. The Plan says that the claim did process correctly per your 
2022 Evidence of Coverage. 
 
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. Specifically, the file does not substantiate the Plan's claim that a filling had 
previously been paid for tooth # 11. Therefore, we decided that the Plan has to pay for the filling (D2335) for 
tooth # 11 provided on January 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D4263) for the upper left and 
upper right quadrants. 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that you have been charged for your 
dentist and have a denied bone replacement graft. The Plan denied your request. The Plan says this service is 
not a covered benefit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement grafts (D4263) for the upper left and upper right quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T9 kyphoplasty (22327, 22514) and for the OsteoAmp 
and Signafuse Allograft (20930). 
 
You asked the Plan to pre-approve the surgical procedures. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the requested services are not 
reasonable or medically necessary at this time. 
 
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 surgical procedures. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented acute or subacute fracture at T9 to justify kyphoplasty. 
OsteoAmp and Signafuse allograft remain experimental at this time. More research is needed.  
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 surgical procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T9 kyphoplasty (22327, 22514) and for the OsteoAmp and Signafuse Allograft 
(20930).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the $60 copayment charged for diagnostic lumbar spinal
puncture with fluoroscopy provided on May 4, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the services provided, the claim
submitted for payment and the Plan contract agreement. Maximus partially overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct contract information.
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 $60 copayment for outpatient diagnostic services. The claim and the medical
records clearly show this was a diagnostic service.
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 $60 copayment charged for diagnostic lumbar spinal puncture with fluoroscopy
provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950), and a crown (D2740) for tooth 
#3 provided by a participating provider. 
 
You asked the Plan to pre-approve a core build-up (D2950), and a crown. You say that the enrollee has 
sensitivity and pain. You say that these services are medically necessary. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
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 a core build-
up (D2950), and a crown when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a core build-up (D2950), and a crown. 
Our reviewer says that D2740 and D2950 are not medically necessary. Our physician reviewer found the 
criteria needed to render these services have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core build-up (D2950), and a crown have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a core build-up (D2950), and a crown (D2740) for tooth #3 provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the dental work requested has been correctly 
denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing (D4341) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $189.98 cost share for diagnostic services provided on
June 28, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract criteria.
The Plan states you are appealing the cost-share assessed for codes 51798, 76872 and 99214 (urine complicity
measure, an ultrasound and a specialist visit) in the amount of $189.98. The Plan states the urine compacity
measure is considered a diagnostic test per Medicare regulation and would be an additional copay. Per NCD
230.2 listed under the Indications and Limitations of Coverage it states "Uroflowmetric evaluations (also
referred to as urodynamic voiding or urodynamic flow studies) are covered under Medicare for diagnosing
various urological dysfunctions, including bladder outlet obstructions." The Plan contract says that outpatient
diagnostic tests-Radiological diagnostic services, not including x-rays have a $155 copayment for Medicare
covered radiological diagnostic services performed in a physician's office or at a free-standing facility (such as
a radiology center or medical clinic). Pages 4-40 to 4-41, Physician/Practitioner Services, Including Doctor's
Office Visits: Consultation, diagnosis, and treatment by a specialist: $25 copayment for services obtained from
a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other
non-physician health care professionals in a specialist's office (as permitted under Medicare rules).
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. Your contract with the Plan clearly states this type of outpatient diagnostic service
requires cost share in addition to the office visit copayment. 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 $189.98 cost share for
diagnostic services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth # 19. 
 
You asked the Plan to pre-approve crown for tooth # 19. You say that your crowns are broken. You say that 
you also have a broken tooth. The Plan denied your request. The Plan says 1 crown is covered per tooth per 60 
months. The Plan also says that the frequency limit has been reached. 
 
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 crown is covered per tooth per 60 
months, the frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 9 
that you received on November 12, 2019. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2740) for tooth # 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee from November
11, 2020, to January 2, 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 claim submitted was incomplete. Maximus overturned the Plans denial for a lack of
information for review. The Plan requested a reopen and stated that a line-by-line itemized bill was not
submitted for review, which is required by Medicare. The Plan states this information was requested several
times with no response.
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 claim
submitted was incomplete. Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for inpatient services provided to the enrollee from November 11,
2020, to January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that these services are medically 
necessary. The Plan denied your request. The Plan says D4266 is not a covered 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. 
 
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 a 
guided tissue regeneration (D4266) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested dental services have been correctly denied. 
 
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 are provided by a participating general dentist.  
 
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 not been met. Therefore, we decided that the Plan does not have to pre-
approve dental services provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $30 copayments charged for specialist telehealth services
provided on May 18, 2021, to June 4, 2021.
You asked the Plan to waive this cost share. You say that these were telehealth services and should not have
this cost share. The Plan denied your request. The Plan says this cost share was applied based on your plan
contract. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply
the correct contract language. The Plan stated that these were telehealth services for urology services. The Plan
states the contract is specific that "specialties are not included in telehealth visits".
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 says that specialty services not listed in the telehealth section are not typically covered as a
telehealth service. Your contract also says specialist visits have a $50 copayment. In this case you are being
charged less than the normal copayment expectation for urology specialist services. 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 $30 copayments charged for specialist telehealth services provided on May 18,
2021, to June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that your dentist has recommended this service. 
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 pre-approve 
gingival irrigation  per quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2752) and core build up (D2950) for teeth # 5 
and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you have mouth cancer. You also say that 
services should be covered. The Plan denied your request. The Plan says the requested dental services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crowns and core build up are not among those covered under this benefit. Additionally, the services you are asking the Plan to pre-
approve 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 pre-approve crowns (D2752) and core build up (D2950) for teeth # 5 and 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213-25) provided on May 5, 2021.
You asked the Plan to pay this claim. You say that this office visit should be covered by the Plan. The Plan
denied your request. The Plan says the records provided do not show this service was billed appropriately.
Maximus overturned the Plans denial stating no medical records were submitted with the case file. The Plan
requested a reopen and provided the required medical records. The Plan stated the medical records show code
99213 was not a distinct and separate service from the osteopathic manipulation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.
In this case, the records provided do not support the services billed. Based on this information, we decided that
Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does
not have to pay for the office visit (99213-25) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on November 16, 2021. 
 
You asked the Plan to pay more for the prophylaxis. The Plan denied your request. The Plan says you were 
reimbursed the maximum dental allowance of $1,500, and no further reimbursement can be issued to you. 
 
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 up to $1,500 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you 
are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit while processing this claim for the November 16, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
prophylaxis (D1110) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) provided by a participating provider. 
 
You asked the Plan to pre-approve a pontic. You say that you disagree with this denial. The Plan denied your 
request. The Plan says the benefit limit for the requested 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. The Plan covers one pontic per 
tooth for life. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a pontic have already been met and exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a pontic (D6240) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing provided on January 6, 2021, billed with 87798.
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 for code 87798 and the remaining codes were
handled under a different claim. Maximus partially overturned the Plans denial stating the outcome of the
decision on the other codes had not been provided. The Plan requested a reopen and provided a copy of the
reprocess and payment of those codes.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly.
Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable
unless a clinically appropriate modifier is used. Code 87798 is a Column 2 code in relation to 87150, which
was also billed on this claim. No clinically appropriate modifier was used to justify bypassing this edit.
Therefore, we decided that the Plan does not have to pay for the testing described by code 87798. As stated,
prior the Plan provided documentation that the other codes mentioned in the appeal were reprocessed and paid.