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

 
We decided that the Plan has to pay for a core build up, including any pins when required (D2950) provided on 
3/15/22. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that benefits are allowed for a core buildup in conjunction with a crown, onlay, or bridge 
abutment only when necessary or essential for retention of the final restoration and preservation of the tooth. 
 
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 services 
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 pay for the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found that the 
reason for the denial was that this procedure is only done in conjunction with a crown. A review of the 
documentation indicates that a crown was removed from tooth #3 due to recurrent caries. Thirty percent of 
tooth structure remained requiring buildup for crown retention. Therefore, the procedure was medically 
necessary and reasonable for crown retention and support. 
 
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 the services have been met. Therefore, we decided that the Plan has to pay for a 
core build up, including any pins when required (D2950) provided on 3/15/22.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $120 coinsurance charged for cardiovascular diagnostic testing provided on November 15, 2021.
You asked the Plan to waive this coinsurance. You say you had to have this test due to doctor error. The Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial because a Plan contract was not submitted with the case file. The Plan requested a reopen and submitted the required contract for review.
Maximus Federal Services read your letter and knows that you may have a quality-of-care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality-of-care concern to the appropriate Quality Improvement Organization for further review.
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 20% coinsurance for outpatient diagnostic services. 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 $120 coinsurance charged for cardiovascular diagnostic testing provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator represented by code E2300, an 
expandable controller represented by code E2377, an expandable harness represented by code E2313, 
electronics represented by code E2311, and push handles represented by code K0108. 
 
You asked the Plan to pre-approve codes E2300, E2377, E2313, E2311, and K0188. You say that the clinical 
information provided supports the need for the items which remain in dispute. The Plan denied your request. 
The Plan says there is not a medical need to control power options through a joystick. The Plan says that the 
push handles requested do not serve a medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that say that for equipment to be covered, it must primarily 
serve a medical purpose.   
 
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 codes E2300, E2377, E2313, E2311, 
and K0188. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has adequate strength to operate the usual control panel 
for a power wheelchair. The Joystick control exceeds what the enrollee requires to meet her needs. In addition, 
push handles do not primarily serve a medical purpose.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2300, E2377, E2313, E2311, and K0188 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a seat elevator represented by code E2300, an 
expandable controller represented by code E2377, an expandable harness represented by code E2313, 
electronics represented by code E2311, and push handles represented by code K0108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission in preparation for shoulder surgery.
You asked the Plan to pay for inpatient admission. You say that due to the enrollee's medical history inpatient admission for this surgery was medically necessary. The Plan denied your request. The Plan says this type of surgery is typically done in an outpatient setting. Clearly if the enrollee required a higher level of care after the surgery was complete the enrollee could have been converted to inpatient at that time. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus tried to anticipate the enrollees needs prior to the services being given.
The Plan is correct in the case. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
Based on the medical records provided, while it is true the enrollee had an extensive health history, she was stable at the time the surgery was requested. In addition, the Plan is correct that if after the surgery the enrollee required an inpatient level of care, her status could have been amended. Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission in preparation for shoulder surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an over-the-counter COVID-19 test purchased on January 19, 2022.
You asked the Plan to pay for this test. You say that this test should be covered by the Plan. The Plan denied your request. The Plan says this testing was not covered under the Plan benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules in place at the time you purchased these tests indicate that over the counter testing was not covered by either Medicare or the Plan for direct reimbursement. You did not contact the Plan for direction prior to making these purchases. Therefore, we decided that the Plan does not have to pay for an over-the-counter COVID-19 test purchased on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for code D0240 or intraoral - occlusal radiographic image.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says while some of these services were paid, code D0240 is not a covered dental service. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information and states Maximus did not address the actual denied code which was D0240.
The Plan is correct in this case. 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.
Code D0240 or intraoral - occlusal radiographic image is not covered by the Plan dental benefit. Therefore, we decided that the Plan does not have to pay this dental service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the extraction, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210) and the bone replacement graft for ridge 
preservation-per site (D7953) provided on June 15, 2022. 
 
You asked the Plan to issue additional payment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
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 
yearly in and out-of-network deductible of $100 that must be paid out-of-pocket before the Plan will pay their 
share for your covered dental services. Enrollees must pay a 20% coinsurance for oral surgery provided out-of-network.  
 
You have been asked to pay $1,036.97 ($750 + $286.97 - $37.03 reimbursement) for the dental services 
provided. This includes the Plan's allowed amount of $146.29 - $100 deductible= $46.29 x 20% coinsurance= 
$9.26. The remaining amount of $46.29 - $9.26 coinsurance= $37.03 issued by the Plan for reimbursement for 
the oral surgery provided. Additionally, a bone replacement graft is not a covered benefit and therefore, the 
billed amount of $750 is your liability for this service. 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 issue additional payment 
for the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and the 
bone replacement graft for ridge preservation-per site (D7953) provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the components of the Comprehensive Cardiac Gene Panel 
provided on November 11, 2022, billed with codes 81404 and 81479. 
 
 You asked the Plan to pay for the genetic testing as billed. You say that this testing should be covered in full. 
The Plan denied your request. The Plan says only partial payment can be made for these services. 
 
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 pay for the genetic testing as billed. Our reviewer 
says that the requested testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the limited clinical documentation does not support that the Comprehensive Cardiac Gene 
Panel testing provided on 11/11/2020, was medically reasonable and necessary for the enrollee in this case. 
This testing was not likely to impact the management and outcomes of the enrollee. 
 
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 genetic testing as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the components of the Comprehensive Cardiac Gene Panel provided on 
November 11, 2022, billed with codes 81404 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the porcelain/ceramic crown (D2740) 
provided on February 21, 2022.  
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service provided. 
 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 50% 
coinsurance for dental crowns. Additionally, for services obtained out-of-network, the Plan pays up to a certain 
amount. If you choose to see an out-of-network dentist you might be billed by that provider for any amount 
greater than what the plan pays, even for services listed as a $0 copayment. 
 
You have been asked to pay $914.50 for the dental crown rendered by an out-of-network provider. This amount 
includes the Plans allowed amount of $549 x 50% coinsurance=$274.50 + $640 (additional amount charged 
by the out-of-network provider beyond the Plans allowed amount). 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 
cost share for the porcelain/ceramic crown (D2740) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81230, 81240, 81241, 81249, 81291, 81408, 
81335) provided on August 22, 2021. 
 
 You asked the Plan to pay for genetic testing. You say that you disagree with the denial of the claim. You have 
submitted medical records for review. The Plan denied your request. The Plan says the billed services were not 
supported. The Plan also says all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests 
must be ordered by the physician who is treating the beneficiary. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records show that the provider did not order the requested 
testing. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81230, 81240, 81241, 81249, 
81291, 81408, 81335) provided on August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the intraoral-complete series of radiographic 
images (D0210) provided on May 12, 2022. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible was applied correctly to the 
service provided. 
 
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 50% 
coinsurance after a $100 deductible for Class 2 Basic Dental Services.  
 
You have been asked to pay a $87.28 deductible for the intraoral x-rays provided. This is the Plan's allowed 
amount for the Class 2 Basic Dental service provided, which is less than the applicable deductible for this 
service. 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 deductible for the intraoral-complete series of 
radiographic images (D0210) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021, billed with 
multiple codes including 81292 and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 4, 2021, billed with multiple codes including 81292 and 81294.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction on May 18, 2022. 
 
You asked the Plan to pay for an extraction. You say that you are appealing the decision based on the wrongful 
submission by the dentist for the type of extraction. 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 an 
extraction on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control (L5973) and addition, endoskeletal system, below 
knee, flexible protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve the K3 foot and protective covering. You say that you are requesting an 
appeal to overturn of the denial of the prosthesis. The Plan denied your request. The Plan says the request for 
L5962 and L5973 exceeds the enrollee's needs and cannot be covered under the Medicare criteria of reasonable 
and necessary. 
 
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 K3 foot and protective covering. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the enrollee currently has a K3 level foot/ankle that is 
under warranty. There is no documentation to support that the member requires an additional protective outer 
surface other than what is provided with the approved replacement prosthesis. The requested advanced 
foot/ankle system and protective outer surface are not medically necessary. 
 
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 K3 foot and protective covering have not been met. Therefore, we decided 
that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control (L5973) and addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that the Plan 
does not cover routine dental services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eleven removals of residual tooth roots (D7250 x11), 
four surgical extractions (D7210 x4), and three alveoloplasties in conjunction with extractions (D7310 x3). 
 
You asked the Plan to pre-approve the removals of residual tooth roots, surgical extractions, and 
alveoloplasties. You say that the enrollee's teeth are broken and non-restorable. The Plan denied your request. 
The Plan says these services are not covered under the enrollee's benefit 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 
eleven removals of residual tooth roots (D7250 x11), four surgical extractions (D7210 x4), and three 
alveoloplasties in conjunction with extractions (D7310 x3).