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

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on September 19, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the root canal. You say that you were unaware the treating provider was out-of-
network. The Plan denied your request. The Plan says you are required to have services performed by a 
contracted dentist under this 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. 
 
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 root canal (D3330) provided on September 19, 2022, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent routine transportation and ground mileage to an out-of-network (OON) provider's office.
You asked the Plan to pre-approve non-emergent routine transportation and ground mileage. You say that you are having many problems going to doctors' visits. The Plan denied your request. The Plan says that the records do not show that your care with the treating provider was approved by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers unlimited trips to a plan-approved location. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The EOC confirms the Plan
covers unlimited trips to a plan-approved location. The requested provider is OON; therefore, transportation is
not approved to this location. Therefore, we decided that the Plan does not have to pre-approve non-emergent routine transportation and ground mileage to an out-of-network (OON) provider's office.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on September 6, 
2022. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your appointment was 
originally scheduled for September 16, 2022, but they called on September 6, 2022, and asked you to come in 
because they had a cancellation. The Plan denied your request. The Plan says that a claim was paid by the Plan 
for an oral evaluation and cleaning provided on date of service March 11, 2022. The Plan also says that you 
were eligible for the Plan to pay for 
another oral evaluation and cleaning after September 07, 2022. 
 
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. 
 
We looked at the file and Medicare rules. The contract says oral examinations and prophylaxes are each limited 
to one every 6 months. The Evidence of Coverage does not specifically state that these services are allowed 
once every 6 months to the day from the last exam and prophylaxis. Based on this information, we decided that 
the Plan's rules for coverage of the periodic oral evaluation and prophylaxis have been met. Therefore, we 
decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on September 6, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you would like to request reconsideration of the authorization. The Plan denied your request. The Plan says that the provider is out-of-network, and it was determined these services can be received in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 
11, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. 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 a $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 copayment 
for specialist office visit provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 09, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the provider depends on hospital 
staff to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on August 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on February 02, 2022, to April 25, 
2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on February 02, 2022, to April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), core buildup, 
including any pins when required (D2950), and adjunctive procedure (D9999) provided on July 15, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, core buildup, and adjunctive procedure. You 
say that the previous statement from the dentist was lacking the identifying codes, and you would like to appeal 
these services. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental plan. The Plan also says that service code D9999 should have been billed as a crown (D2740), which is 
also not listed as a covered service under your dental 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 first 
intraoral periapical x-ray (D0220), core buildup, including any pins when required (D2950), and adjunctive 
procedure (D9999) provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) 
provided on March 18, 2022. 
 
You asked the Plan to pay for the palliative (emergency) treatment of dental pain (D9110). You say that the 
dentist billed this procedure as an emergency, but it was not an emergency. 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 palliative (emergency) treatment of 
dental pain (D9110) is not among those covered under this benefit. The medical record shows the appointment 
was provided as a palliative service due to pain. Therefore, we decided that the Plan does not have to pay for 
the palliative (emergency) treatment of dental pain (D9110) provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for this testing. The ordering physician requested prior authorization for this test on August 24, 2021, which was denied by the Plan on August 27, 2021. The testing services provided on September 29, 2021, were denied prior to being rendered.
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 contract also states this type of testing requires prior authorization. The testing provider in this case is not a network provider with the Plan. Prior authorization was requested and denied prior to the service being rendered. The medical records provided do not demonstrate that the results of this testing would directly affect treatment of the enrollee, nor do they show the enrollee met the required criteria for this testing. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a repeat epidural steroid injection for the enrollee.
You asked the Plan to provide coverage for these services. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. After we made our decision, we reopened the case due to errors found in processing.
Upon reopen, our Medical Director looked at the case file and the reopen request. At issue is coverage for repeat epidural steroid injection (ESI) at the L5-S1 level. The medical records show an anesthesia telemedicine visit reportedly occurred on August 18, 2021, however the case file does not contain a dated anesthesia note. The enrollee was a then 65-year-old man with a diagnosis of chronic recurrent lumbar radiculopathy, with pain in his low back and buttocks. Failed conservative therapies included physical therapy, a home physician-directed exercise program, ice, heat, pain medications including NDAIDs, acetaminophen, muscle relaxers, and neuropathic agents. The enrollee had functional impairment, with difficulties performing ADLs, and pain levels of 7-8 out of 10. The enrollee reported excellent pain relief from a prior injection, greater than 70%, in addition to significant functional improvement in daily activities. On September 10, 2021, at a "Readmission reduction visit", the enrollee reported a 0 out of 10 level of pain and was in no acute distress. The medical records do not contain sufficient documentation to support the medical necessity of repeat lumbar epidural steroid injection. There is no documentation of a physical examination demonstrating radiculopathy. There are not imaging reports. The date and details of the previous epidural steroid injection were not reported. Medical necessity for a repeat injection was not established.
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 provide coverage for a repeat epidural steroid injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 18, 2022. 
 
You asked the Plan to pay for a home visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, posterior tooth # 02 
(D2391), and resin-based composite - two surfaces, posterior tooth # 31 (D2392). 
 
You asked the Plan to pay for the dental services. You say that you were told the fillings would be covered at 
50%. You also say that had you known you had reached your benefit maximum you would not have had the 
work done. The Plan denied your request. The Plan says your benefit for the requested items or services $500 
dollar limit was 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. 
 
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 September 28, 2022. Therefore, we decided that the Plan does not have to pay for a resin-based composite - one surface, posterior 
tooth # 02 (D2391), and resin-based composite - two surfaces, posterior tooth # 31 (D2392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and extraction (D0140, D7210) 
provided on March 10, 2022. 
 
You asked the Plan to pay for the limited oral evaluation and extraction. 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 pay for a limited 
oral evaluation and extraction (D0140, D7210) provided on March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on February 
23, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 a $325 
copayment for outpatient surgery/Medicare-covered surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery 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 copayment 
for an outpatient surgery provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on July 15, 2022 
 
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 January 14, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on July 15, 
2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 27, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 a $35 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist visit 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 copayment 
for a specialist office visit provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kits (87426) and sales tax (S9999) 
purchased on January 19, 2022. 
 
You asked the Plan to pay for the COVID-19 test kits and sales tax. You say that each person can buy OTC 
home test kits and should be reimbursed by their insurance. The Plan denied your request. The Plan says your 
medical plan does not cover OTC test kits. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan. Medicare rules also say that Medicare does not make separate payment for sales tax.  
We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the COVID-19 test kits (87426) and sales tax (S9999) purchased on January 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), intraoral radiographic image 
(D0210), crown (D2740), fabricated post and core (D2952), endodontic therapy (D3330), guided tissue 
regeneration (D4266), and bone replacement graft (D7953) for tooth #14 and #19 provided on September 13, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reimburse you for the 
dental services. The Plan denied your request. The Plan says your yearly maximum dental benefit 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 items or services was exhausted on the date of service of September 13, 
2021. On September 13, 2021, the Plan paid $200, $650, and $150 for the dental services which totals to an 
amount of $1,000 ($200 paid + $650 paid, + $150 paid). Therefore, we decided that the Plan does not have to 
pay for an oral evaluation (D0140), intraoral radiographic image (D0210), crown (D2740), fabricated post and 
core (D2952), endodontic therapy (D3330), guided tissue regeneration (D4266), and bone replacement graft 
(D7953) for tooth #14 and #19 provided on September 13, 2021.