Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $110 copayment charged for a diagnostic ultrasound
provided on December 10, 2020.
You asked the Plan to waive this copayment. You say that this service was cancelled. The Plan denied your
request. The Plan says this copayment was charged based on the services provided and the Plan contract
agreement. Maximus overturned the Plans denial for a lack of medical records in the file to support the correct
cost share was applied. The Plan requested a reopen and provided the required medical records.
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 for outpatient diagnostic services. The Plan provided medical records to show
you were provided with an echocardiogram on December 10, 2020.
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 $110 copayment charged for a diagnostic ultrasound provided on December 10,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 6, 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 Medicare coverage criteria were not met. Maximus overturned the Plans denial for a
lack of information in the case file. The Plan requested a reopen and provided additional information. The Plan
stated that the Plan contacted the ordering physician listed on the request on June 22, 2021. It was confirmed
that the physician did not order the genetic testing for the enrollee. The Plan stated that since the ordering
physician listed denies writing the order for genetic testing, these services are not payable. In addition, the
place of service reported should be where the specimen was obtained. The submitted medical records contain
discrepancies with the reported place of service noted on the submitted claim form. Therefore, the billed
code and place of service cannot be verified.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that Medicare
requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the
beneficiary in accordance with Medicare's policies. Medicare also requires claims to reflect the appropriate
place of service codes.
It has been confirmed that the place of service listed is not cored and the documentation submitted does not
include a valid signature from the persons responsible for the care of the beneficiary. Therefore, we decided
that the Plan does not have to pay for genetic testing provided to the enrollee on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on 
September 21, 2021. 
 
You asked the Plan to pay for the partial denture. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental consultation (D9310) provided on October 21, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
consultation (D9310) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair or nonroutine services (K0739). 
 
You asked the Plan to pre-approve repair services. You say that this is medically necessary for your condition. 
The Plan denied your request. The Plan says this service is not covered according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the reimbursement for the wheelchair codes 
includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support 
services, such as delivery, set-up, and education about the use of the power mobility device. 
 
We looked at the file and Medicare rules. The labor services are included within the payment for the base 
wheelchair and will not be paid separately. Based on this information, we decided that Medicare rules for 
coverage of repair services have not been met. Therefore, we decided that the Plan does not have to pre-
approve repair or nonroutine services (K0739).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140) and 
extractions (D7140 x 13) provided on October 26, 2021. 
 
You asked the Plan to pay an additional amount for the limited oral evaluation and 13 extractions. You say that 
you would like to be reimbursed for some of the amount that you had to pay for the extractions. The Plan 
denied your request. The Plan says that the annual maximum benefit of $2,000 has been exhausted.  
 
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 and the services are listed as covered, 
the annual maximum benefit of $2,000 has been exhausted. The record shows that the Plan paid $99.60 for 
services you received on November 12, 2021, $299.40 for dental services received on October 25, 2021, and 
$1,601 for dental services received on the date of service in this case. $99.60 + $299.40 + $1,601 = $2,000.  
Therefore, we decided that the Plan does not have to pay an additional amount for the limited oral evaluation 
(D0140) and extractions (D7140 x 13) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that these services were medically 
necessary. You say that you would like the Plan to reprocess and pay for these services. The Plan denied your 
request. The Plan says services provided by an out-of-network provider are 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 Plan's coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing when the services are provided by an out-of-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling and root planing (D4341) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical connection between power systems (E2311), 
power seat elevation feature (E2300), and push handles (K0108). 
 
You asked the Plan to pre-approve the power wheelchair equipment. You say that these items are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say a power seat elevation feature (E2300) is non-covered because it is not 
primarily medical in nature. The rules say an electrical connection between power systems is covered if it is 
medically necessary for the enrollee to control two or more motors from a single interface. 
 
The push handles and power seat elevation feature do not serve a purpose that is primarily medical in nature. 
These items are available to the general public and would be helpful even to those who are not sick or injured.  
 
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 for the electrical connection between power systems. 
Our reviewer says that the requested item is not medically reasonable in nature. Our physician reviewer found 
that the member has a neurologic disorder with functional deficits. She meets criteria for use of a power 
mobility device. The requested accessories are not medically necessary as she does have use of her hands and 
can operate and control the power options using the switches that are included in the basic wheelchair. 
 
Therefore, we decided that the Plan does not have to pre-approve electrical connection between power systems 
(E2311), power seat elevation feature (E2300), and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional hours of neuropsychological testing 
evaluation services (96133). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that these testing 
services are medically necessary. The Plan denied your request. The Plan says there is no medical need for 
services beyond what have been approved. 
 
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 neuropsychological testing evaluation 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 79-year-old male is requesting 
additional neuropsychological testing. This patient has shown impairment in functioning as documented. He has been showing difficulty with mood and cognitive issues as outlined using the interpretation. There was no 
documentation that justifies the extra amount of time in the testing and assessment. Based on review the 
records provided and the information provided this patient does not meet the criteria for additional 
neuropsychological testing beyond which is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 8 additional hours of neuropsychological testing 
evaluation services (96133).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of all four 
quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you need this treatment to be 
approved in hopes of saving your teeth. The Plan denied your request. The Plan says that the x-rays do not 
show that you have noticeable bone loss, or a hard substance built up on the root of the tooth. 
 
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 digital quality x-rays for this 
case. We asked for these x-rays, but they were not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has 
not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve 
periodontal scalings and root planings (D4341) of all four quadrants.  
 
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 pay for five additional porcelain/ceramic crowns (D2740) provided 
on October 28, 2020. 
 
You asked the Plan to pay for crowns. You say that these services were medically necessary. The Plan denied 
your request. The Plan says they have agreed to pay for two of the seven crowns provided on this date; 
however, your benefit covers a maximum of two crowns per year and the remaining crowns exceed this 
limitation. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover two 
crowns per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crowns are requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
five additional porcelain/ceramic crowns (D2740) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120), to be provided by an out of network provider. 
 
You asked the Plan to pre-approve the dental items. You say that you were advised this dental office was in 
network. The Plan denied your request. The Plan says dental items received out of network 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dentures to be received 
out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120), to be provided 
by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered 
by a periodontist. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you need the periodontal 
care, even if it is not with the doctor that is on the authorization. The Plan denied your request. The Plan says 
dental services performed by a periodontist 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 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered by a 
periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 23, 
2021. 
 
You asked the Plan to pay for the limited exam. You say that this service was necessary. The Plan denied your 
request. The Plan says you had a previous limited oral exam on August 12, 2021, which was covered by the 
Plan. This service is only covered once per plan year. 
 
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 can cover one 
limited exam to evaluate a problem (D0140) per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a 
frequency that is not covered under this benefit. Documentation shows that the Plan has paid for a previous 
limited exam for you in 2021. Therefore, we decided that the Plan does not have to pay for the limited oral 
exam (D0140) provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental in cases of spinal fusion surgery when used as bone graft material. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and porcelain/ceramic crown 
(D2740) provided on November 4, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that you did not know these services would 
not be covered and would like at least partial payment for this treatment. The Plan denied your request. The 
Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) and porcelain/ceramic crown (D2740) provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic 
connection. 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness is covered 
to control multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the expandable controller with harness and 
electronic connection are not needed to control the approved power switches. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller with harness and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
panoramic x-ray (D0330) provided on November 8, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray. You say that you 
were unaware that these services would not be covered by Medicare. You also say that the dental company 
performed these x-rays without telling you this. The Plan denied your request. The Plan says these services are 
not covered expenses 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extractions for teeth # 29 and 30 provided on 
August 25, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that the services should be covered. The 
Plan denied your request. The Plan says 2 extractions are covered per calendar year. The Plan also says that the 
frequency limit has been exceeded. 
 
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 2 extractions are covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 extractions that 
you received on January 11, 2021. Therefore, we decided that the Plan does not have to reimburse you for the 
extractions for teeth # 29 and 30 provided on August 25, 2021.