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

 
We decided that the Plan does not have to pay for endodontic therapy (D3310) provided by an out-of-network 
provider on June 7, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you think the Plan should pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until November 9, 2023. Therefore, we decided that the Plan does not 
have to pay for endodontic therapy (D3310) provided by an opt-out provider on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete upper and lower denture 
(D5110, D5120) provided on June 1, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you feel that the provider is 
overcharging for the dentures. You also say you are dissatisfied with the quality of the items. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for prosthodontics.  
 
You have been asked to pay a $1,020 cost-share for the dental services. See below for a breakdown of your 
cost-share. 
 
Allowed amount per denture = $1,275  40% coinsurance = $510  2 sets of dentures = $1,020 
 
This item/service falls within the dental services benefit category. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are subject to a coinsurance. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a complete upper and lower denture (D5110, D5120) provided on 
June 1, 2022.  
 
Your complaint about the material quality of the dentures you received is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints. The record shows that the Plan has submitted a 
quality-of-care complaint on your behalf. Maximus cannot address quality of care concerns. Please contact the 
Plan for further information regarding this concern.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 6, 2021, to April 9, 2021.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this should be paid for. The Plan denied your request. The Plan says payment of DRG 291 remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with DRG 291 and diagnosis code J96.01. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that there was no noted documentation of respiratory rates greater than 30, use of accessory muscles, or documentation of persistent decline in SpO2 breathing the member's usual FIO2 following focused treatment in the emergency department. Although the provider documented Acute respiratory failure with hypoxia, reasonable support within the health record must be present for that diagnosis. The review has determined that the records did not support the use of DRG 291 in this case. The plan's revised DRG 292 is more appropriate. J96.01 - acute respiratory failure with hypoxia was not appropriate in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 6, 2021, to April 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 3, 2022.

You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code.

We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered 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 pay for the dental 
services on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided by a 
participating provider on May 23, 2022. 
 
You asked the Plan to pay for panoramic radiographic imaging. You say that you believe that this dental work 
should be paid. The Plan denied your request. The Plan says the rendered dental service is not a covered 
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 pay for 
panoramic radiographic imaging (D0330) provided by a participating provider on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment and crown restoration 
(D6059, D6057) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve a 
custom fabricated abutment and crown restoration (D6059, D6057)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and an electrocardiogram routine ECG provided on June 14, 2022, by an out-of-network provider.

You asked the Plan to pay for the office visit and electrocardiogram routine ECG. You say that this provider saved you from going to the emergency room. The Plan denied your request. The Plan says the provider is not contracted with the health Plan and the member does not have out-of-network benefits. There is no documentation that this member was referred to this non-contracted provider by a contracted provider, as
well as no indication of any attempt made to obtain prior authorization for the out-of-network services.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit and an electrocardiogram routine ECG provided on June 14, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown. 
 
You asked the Plan to pre-approve a porcelain crown. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says your x-rays show your teeth to have 
more than 50% loss. This will lead to a questionable long-term prognosis. This tooth does not meet clinical 
requirements for a crown benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a porcelain 
crown when the services are medically necessary and reasonable.  
 
Based on this information, we decided that the Plan's rules for coverage of a porcelain crown have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on July 6, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you were unaware that your husband did not 
have comprehensive dental insurance. The Plan denied your request. The Plan says the rendered dental service 
is not a covered 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 pay for intraoral 
imaging (D0210) provided by a participating provider on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) and panoramic radiographic 
imaging (D0330) provided by a participating provider on July 5, 2022. 
 
You asked the Plan to pay for intraoral imaging and panoramic radiographic imaging. You say that these 
services were necessary. The Plan denied your request. The Plan says the rendered dental services are not 
covered 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 intraoral 
imaging (D0210) and panoramic radiographic imaging (D0330) provided by a participating provider on July 5, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make a one-time exception for periapical radiographic imaging 
(D0220) and 2D oral photographic image (D0350) provided by a participating provider on July 12, 2022. 
 
You asked the Plan to make a one-time exception for the dental services. You say that your dentist retired. You 
say that you went for a routine visit. The Plan denied your request. The Plan says your benefit for D0220 has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the D0220 was exhausted on date of service July 12, 2022. The Plan does not cover 
D0350. Therefore, we decided that the Plan does not have to make a one-time exception for periapical radiographic imaging (D0220) and 2D oral photographic image (D0350) provided by a participating provider 
on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #23 (D2740). We also decided that the Plan does 
not have to pre-approve a crown on tooth #26 (D2740).  
 
You asked the Plan to pre-approve crowns on tooth #23 and 26 (D2740). You say that the crowns are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
 
 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 crown when 
the services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve a crown on tooth #23 (D2740).  
 
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 crown on tooth #23. Our reviewer 
says that the coverage criteria for a crown on tooth #23 has been met. Our physician reviewer found that a 
review of the documentation indicates that tooth #23 exhibits significant coronal breakdown due to large 
defective restoration. There appears to be adequate bone support (50%). A crown restoration is reasonable and 
necessary to provide adequate strength and function. 
 
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 crown on tooth #23 have been met. Therefore, we decided that the Plan has to 
pre-approve crowns on tooth #23 (D2740).  
 
We also decided that the Plan does not have to pre-approve a crown on tooth #26 (D2740). 
 
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 crown on tooth #26. Our reviewer 
says that the coverage criteria for a crown on tooth #26 has not been met. Our physician reviewer found that 
tooth #26 does not appear to have significant coronal breakdown due to caries or fracture to warrant a crown 
restoration. 
 
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 crown on tooth #26 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown on tooth #26 (D2740). 
 
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 surgical access to an implant body and modification of a 
prefabricated abutment (D6011 D6056) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve 
surgical access to an implant body and modification of a prefabricated abutment (D6011 D6056)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 30, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed emergency 
dental treatment, and you would like the Plan to pay for the services. The Plan denied your request. The Plan 
says this service is not a covered expense under your dental plan. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard, or nightguard (D9946), provided on June 
14, 2022. 
 
You asked the Plan to pay for a nightguard. You say that you were grinding your teeth during your sleep, and it 
was causing the enamel on your teeth to wear down. You also say you were experiencing migraine headaches 
and jaw and neck pain. The Plan denied your request. The Plan says the item at issue is not a covered benefit 
under your contract. 
 
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 an 
occlusal guard, or nightguard (D9946), provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services requested are not covered 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 the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that there was a frequency 
limit for this procedure. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 30, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 25, 2022, to May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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. 
 
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 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 the dental services on March 25, 2022, to May 6, 2022.