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

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220) 
 
You asked the Plan to pay for 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 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 July 13, 2022. Therefore, 
we decided that the Plan does not have to pay for a periapical x-ray (D0220)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition of a tooth to an existing partial denture 
(D5650) provided by a participating provider. 
 
You asked the Plan to pre-approve the addition of a tooth to an existing partial denture. You say that the 
requested dental service is not a covered benefit. The Plan denied your request. The Plan says the requested 
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 pre-approve the 
addition of a tooth to an existing partial denture (D5650) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470) provided on June 20, 2022. 
 
You asked the Plan to pre-approve diagnostic casts (D0470). You say that the dental bill was denied. The Plan 
denied your request. The Plan says this service is not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
diagnostic casts (D0470) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth requiring removal of bone 
provided on June 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not told that the provider was 
not participating in Medicare programs. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the extraction, erupted tooth requiring 
removal of bone provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), intraoral imaging (D0220), and a resin-
based composite (D2394), provided by an out-of-network provider on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that all other in-network providers are booked too 
far out. 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 bitewings (D0274), intraoral imaging (D0220), and a resin-based composite (D2394), provided by an 
out-of-network provider on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 28, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist office because of pain 
and the Plan should cover the denied dental service. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the limited oral evaluation is not covered by the 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 pay for the 
limited oral evaluation (D0140) provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor - lesion 
diameter greater than 1.25 cm (D7451). 
 
You asked the Plan to pay for the removal of benign odontogenic cyst or tumor. You say that it is necessary to 
have a cyst removed. 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 pay for the 
removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm (D7451).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal scaling and root planing 
(D4341) provided on November 13, 2019, resin-based composite fillings on tooth #12, 13, 14, 15, 18, 20, and 
21 (D2391, D2392, D2393) and periodontal scaling and root planing (D4341) provided on November 18, 2019, resin-based composite fillings on tooth #2, 3, 4, 28, 29, and 31 (D2391, D2392) provided on November 20, 
2019, and a resin-based composite filling on tooth #18 (D2392) provided on November 26, 2019. 
 
You asked the Plan to waive the coinsurance for periodontal scaling and fillings. You say that you were 
unaware of this balance for over two years. The Plan denied your request. The Plan says this cost sharing was 
charged 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 50% 
coinsurance for peridontal scaling and root planing. The Plan contract also says that enrollees must pay 20% 
coinsurance for restorative dental services, including fillings. 
 
You have been asked to pay 50% coinsurance of the allowed amount for periodontal scaling received on 
November 13, 2019, and November 18, 2019. You have also been asked to pay 20% coinsurance of the 
allowed amount for fillings received from November 18, 2019, to November 26, 2019.  
 
Date Code Tooth # Allowed Amount Coinsurance 
November 13, 2019 D4341  $122 $61 
November 13, 2019 D4341  $122 $61 
November 18, 2019 D2392 12 $105 $21 
November 18, 2019 D2392 13 $105 $21 
November 18, 2019 D2392 14 $105 $21 
November 18, 2019 D2392 15 $105 $21 
November 18, 2019 D2393 12 $136 $27.20 
November 18, 2019 D2391 13 $77 $15.40 
November 18, 2019 D2391 18 $77 $15.40 
November 18, 2019 D2391 20 $77 $15.40 
November 18, 2019 D2391 21 $77 $15.40 
November 18, 2019 D4341  $122 $61 
November 18, 2019 D4341  $122 $61 
November 20, 2019 D2391 28 $77 $15.40 
November 20, 2019 D2391 29 $77 $15.40 
November 20, 2019 D2392 2 $105 $21 
November 20, 2019 D2392 3 $105 $21 
November 20, 2019 D2392 4 $105 $21 
November 20, 2019 D2392 31 $105 $21 
November 26, 2019 D2392 18 $105 $21 
 
Periodontal scaling and fillings fall within the dental services 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 coinsurance for periodontal scaling and root planing (D4341) provided on November 13, 2019, 
resin-based composite fillings on tooth #12, 13, 14, 15, 18, 20, and 21 (D2391, D2392, D2393) and periodontal 
scaling and root planing (D4341) provided on November 18, 2019, resin-based composite fillings on tooth #2, 
3, 4, 28, 29, and 31 (D2391, D2392) provided on November 20, 2019, and a resin-based composite filling on 
tooth #18 (D2392) provided on November 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services billed to the enrollee form July 22, 2021, to August 20, 2021.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was submitted with an incorrect discharge code. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states the provider billed the claim with a discharge code of "06" which indicates the enrollee did not stay for a 30-day period of care. However, the Plan notes that July 22nd to August 20th, 2022, counts as 30 days (10 days in July and 20 days in August) as the admission and discharge day are counted. Therefore, the discharge code of "06" was incorrect as the enrollee did not stay less than 30 days.
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 this claim cannot be paid as billed due to an error with the discharge code. 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 home health services billed to the enrollee form July 22, 2021, to August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 28, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be a $0 copayment under 
your vision care benefit. The Plan denied your request. The Plan says this cost sharing was charged 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 20% of 
the cost for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
 
 
 The record shows this claim was approved, and you are responsible for a cost-sharing amount. You have been 
asked to pay $372.99, which is 20% coinsurance of the allowed amount for an injection ($1,864.97 x 20% 
coinsurance = $372.99). This item/service falls within the Medicare Part B prescription drugs 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 coinsurance for an injection provided on June 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs coded J3490 provided on March 23, 
2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 CPT code. 
 
 
 
 
 
 
 
 
 
 We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided 
within the global surgery period as it was provided on the same date of service as the surgery procedure. This 
means this service is not separately payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the unclassified drugs have not been met. Therefore, we decided that the Plan does not 
have to pay for the unclassified drugs coded J3490 provided on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents. 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. You say that the enrollee has 
severe, limiting right lower extremity pain, and uses a cane to ambulate. You also say that you would like to 
obtain a lumbar MRI to rule out acute disc herniation that may be causing these symptoms. The Plan denied 
your request. The Plan says that the medical documentation submitted for review indicates that the enrollee has 
lower back, right hip and right leg pain. The Plan also says that the documentation does not indicate that the 
enrollee has completed at least six weeks of provider directed treatment within the past three months followed 
by clinical re-evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the spinal canal and 
contents. Our reviewer says that an MRI of the spinal canal and contents is reasonable and necessary for the 
enrollee. Our physician reviewer found the enrollee has been prescribed a Medrol dose pack and Gabapentin 
with no relief. The enrollee's plain x-rays show degenerative changes at L4-5. Our reviewer found the enrollee's 
neurological exam is completely within normal limits with no weakness, straight leg raise, reflex. The plan is 
for physical therapy (PT) referral and an MRI of the lumbar spine. Our physician reviewer also found that the 
history of the administration of oral steroids and Gabapentin without relief provide a plan recognition of the 
indication for an MRI, even though PT has not yet occurred, and the neurological exam is normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the spinal canal and contents have been met. Therefore, we decided 
that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and contents.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the lidocaine injection provided on November 10, 2021.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct coding criteria. The Plan
demonstrated that a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between codes 20611 and J2011. Per National Correct Coding Initiatives (NCCI), the PTP edit between these
code pairs has a modifier indicator of "1" which states modifiers associated with NCCI are allowed, however,
an appropriate NCCI modifier was not billed.
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 and when necessary, the
appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of the required
modifier. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan
does not have to pay for the lidocaine injection provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for vision services and hardware provided on April 19, 2022.
You asked the Plan to pay additional reimbursement. The Plan denied your request. The Plan says this cost share was charged correctly. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated that they allowed the full allowance of $200 for the routine vision hardware obtained. However, due to the participating provider's contract with the Plan, $7.30 was withheld on the claim. The Plan withholds a portion of the payment that is otherwise owed to the participating provider as part of an arrangement between the provider and the Plan. This withhold amount is then placed in a risk pool fund held by the Plan until the end of the calendar year.
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 the Plan pays a maximum of $200 for vision hardware every two calendar years.
The Plan has provided documentation to show they paid the maximum $200, and the $7.30 remaining is a processing fee between the contracted provided and the Plan. Therefore, we decided that the Plan does not have to pay additional reimbursement for vision services and hardware provided on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that medical records have been submitted to 
confirm necessity. The Plan denied your request. The Plan says the requested ventilator does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. 
However, there are no ABGs done while stable documenting chronic CO2 retention. Even if the enrollee does 
have chronic CO2 retention, BiPAP with AVAPS would be the treatment of choice. Medicare does not cover a 
home ventilator when used at settings that could be provided by BiPAP, at less cost to 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation shows that you have complex neuro deficits, and the 
evaluating therapists are recommending intense therapy thus you would require interdisciplinary team 
management and intense therapy. The clinical documentation also shows that you are at high risk for post 
stroke complications and would be expected to require hospitalization during rehabilitation for close medical 
supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan has to pre-
approve acute IRF admission and services.  
 
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.