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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) and unspecified preventive service 
(D1999) provided on December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that at no time were you told that the provider was 
out of network. You say that the dental office advised they would file a claim for you and to expect to get 
payment from your plan. The Plan denied your request. The Plan says the provider in this case is out of 
network. The Plan also says that dental services 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis (D1110) and unspecified preventive service (D1999) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0272), and prophylaxis (D1110) provided on October 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that 
you had gone to this dentist prior to having dental insurance and assumed they were in your Plan's network. 
You also say that you were not informed that they were not in-network. The Plan denied your request. The Plan 
says your liability amounts were applied correctly. The Plan also says that cost sharing is a contractual 
obligation under the Plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount because these services were received OON. Therefore, we 
decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0272), and prophylaxis (D1110) provided on October 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you need the implants. The Plan denied 
your request. The Plan says this service is not covered under your benefit plan. 
 
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 pre-approve 
surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental service. You say that you are new to the area and have not family. 
You say that you were advised you needed this service to prevent your teeth from falling out. You say that you 
do not have the money to get this done. You also say that you feel the services should be covered. The Plan 
denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service. 
 
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 periodontal scaling and 
root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that you had a deductible of $100.00 per year which is coming off the top and is why you are paying more. You 
also say that you were not aware that the coverage is at only 50%, and you thought you would only be liable for 
20%. The Plan denied your request. The Plan says you are contractually obligated to pay a $100 deductible per 
calendar year and a 50% coinsurance for these services. 
 
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, you are responsible for a $100 
deductible per calendar year, plus 50% of the cost for each visit for covered prosthodontic and prosthodontic 
maintenance services. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary 
denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that it is your recommendation 
that the tori be removed so the enrollee may receive a mandibular denture. The Plan denied your request. The 
Plan says this service is not covered under the enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
removal of torus mandibularis (D7473).
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), prophylaxis 
(D1110), and resin-based composite (D2391) for tooth #30, or pay more for the resin-based composite (D2391) 
for tooth #18 provided on October 5, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays, prophylaxis, and resin-based composite 
(D2391) for tooth #30, and to pay more for the resin-based composite (D2391) for tooth #18. You say that you 
have Dystonia, a movement disorder in which your muscles contract involuntarily, muscle spasms, and 
abnormal posturing causing repetitive or twisting movements. You also say that in order for you to have any 
kind of dental or medical services, it must be done under general anesthesia. The Plan denied your request. The 
Plan says your calendar year maximum has been reached, and you are responsible for the balance of $523. 
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 Plan offers a $3,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the October 5, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
complete series of intraoral x-rays (D0210), prophylaxis (D1110), and resin-based composite (D2391) for tooth 
#30, or pay more for the resin-based composite (D2391) for tooth #18 provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Exo DX test. 
 
You asked the Plan to pre-approve an Exo DX test. You say that you requested this test to avoid complications 
by using non-invasive testing before the last resort of a biopsy. You say that the requested test has the least 
exposure and unwanted side effects. The Plan denied your request. The Plan says the requested test is 
investigational and not of clinical validity or significance. 
 
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 an Exo DX test. Our reviewer says that 
an Exo Dx test is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the records do not confirm the test results will confirm a diagnosis or known information. Records indicate the 
treating provider will schedule the enrollee for a prostate biopsy which will confirm the diagnosis. 
 
 
 
 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 Exo DX test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Exo DX test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Retacrit or Procrit before they will approve the requested drug. In this case, the patient has not tried and failed 
the required drug(s). There is no documentation provided indicating that the plans required drug(s) would 
likely be less effective and/or likely have adverse effects for 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an off-campus outpatient hospital setting and should have been billed with POS code 19. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 22, 2021 and billed under code 70450.
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 a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit
exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, which indicates modifiers
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed on the claim.
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 due to the omission of the required modifier. 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 pay for imaging services provided to the enrollee on October 22, 2021 and billed
under code 70450.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0425-GY, A0429-GY) provided on September 21, 2021.
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary as you were bleeding profusely, and your spouse rarely drives and was far too upset to drive after your accident. The Plan denied your request. The Plan says these services were billed with the GY modifier and therefore are statutorily excluded from Medicare coverage.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The services in this case were billed with a GY modifier, which by definition means that these services do not meet Medicare criteria and are excluded from coverage. The provider in this case is not contracted with the Plan, and the Plan does not have the authority to change the submitted claim. If you feel these services were billed inappropriately, you would need to contact the ambulance provider directly and request a corrected claim be submitted to the Plan. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0425-GY, A0429-GY) provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathogen testing (87486, 87581, and 87798). We note that on
reopen the Plan has provided confirmation that code U0003 for Covid testing was paid.
You asked the Plan to pay for pathogen testing and covid testing. You say that this claim should be paid. The
Plan denied your request. Maximus partially overturned the Plans denial and ordered payment of the covid
testing and upheld the pathogen testing. The Plan requested a reopen and provided proof that the covid testing
was approved and paid.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that lab testing may be
covered when ordered by a treating physician. The order does not document the intent to perform testing for the
other specific pathogens described by codes 87486, 87581, and 87798. The Plan has now provided
confirmation that the covid testing, code U0003, has been paid. Therefore, we decided that the Plan does not
have to pay for the other pathogen testing provided on January 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a digital thermometer.
You asked the Plan to pre-approve a digital thermometer. You say that you are appealing the denial getting a handheld digital thermometer. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a digital thermometer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth #6, #7, #8, #9 and #11.
You asked the Plan to pre-approve clinical crown lengthening. You say that when you switched your coverage Plan, you were told that you would be covered for unlimited dental coverage. You are requesting that what you were told during the Plan's orientation is honored. The Plan denied your request. The Plan says the requested service is not covered under your dental coverage Plan.
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 pre-approve clinical crown lengthening (D4249) for tooth #6, #7, #8, #9 and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation
(92004), the visual field examination (92083), and the fundus photography with interpretation and report
(92250) rendered by the out-of-network (OON) provider on November 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004), the visual field examination (92083), and the fundus photography with interpretation and report (92250) rendered by the out-of-network (OON) provider on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 17, 2021.