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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not refuse the transport. You also say that you would have gladly accepted the transport if the medical response 
deemed it necessary. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 3, 2022.  
 Your complaint about the 2022 member handbook is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on  
August 12, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electric stimulation therapy (97014) provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three surgical extractions (D7210 x3), or pay more for 
the complete maxillary denture (D5110), and mandibular partial denture (D5214) provided on August 3, 2022, 
and September 7, 2022. 
 
  You asked the Plan to pay for the extractions, and to pay more for the complete maxillary denture, and 
mandibular partial denture. You say that you were told you would have $2,000 for dental services per year, but 
you were not advised that you were only allowed 2 extractions per year. You also say that you would like at 
least some of the remaining balance you owe alleviated by the Plan. The Plan denied your request. The Plan 
says your extractions benefit has been satisfied and the frequency limitation has been exceeded. The Plan also 
says that you were not misinformed during your calls to the Plan, and were correctly advised that two 
extraction procedure codes are covered at 50% per calendar year when rendered in-network, and you were 
advised that the Plan would cover one upper and/or one lower denture at 30% every five years from an in-
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to 2 procedure 
codes per calendar year. The record shows that your extractions benefit was exhausted on dates of service 
August 3, 2022, and August 17, 2022. You were correctly charged a 50% coinsurance for each of the two 
extractions that were covered by the Plan. You are also responsible for a 70% coinsurance for each complete 
denture and removable partial denture you receive from an in-network provider. Therefore, we decided that the 
Plan does not have to pay for the three surgical extractions (D7210 x3), or pay more for the complete maxillary 
denture (D5110), and mandibular partial denture (D5214) provided on August 3, 2022, and September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical removal of erupted tooth (D7120) for tooth #32 
provided on October 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary to get the dental 
procedure done. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the surgical removal of erupted tooth 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical 
removal of erupted tooth (D7120) for tooth #32 provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), and gingival 
irrigation (D4921), provided on October 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to a new dentist. The Plan denied your 
request. The Plan says your benefit for D4341 has already been exhausted. D4921 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 29, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), and 
gingival irrigation (D4921), provided on October 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT Scan provided on January 20, 2022. 
 
You asked the Plan to pay for CT Scan. You say that you are requesting reconsideration. 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 CT Scan provided on 
January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET) 
scan; metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
Disease (AD) and Frontotemporal Dementia (FTD). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case the enrollee was 
being evaluated for memory problems. However, the neurology consult notes provided for review did not 
indicate that the enrollee met diagnostic criteria for both Alzheimers Disease and Frontotemporal Dementia. 
Rather they suggested a mood disorder and/or vascular process as a cause of symptoms. Therefore, the enrollee 
does not meet criteria for coverage of the requested service as defined by Medicare rules.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET) scan; metabolic evaluation (78608).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan 
 
You asked the Plan to pre-approve the CTA scan. 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 meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CTA scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that since the CTA has already been done 
on December 20, 2022, and showed no arterial abnormality there is no documented reason to do a repeat exam. 
 
 
  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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography angiography (CTA) scan
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 03, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. 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 domiciliary or rest home 
visit provided on August 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network medical exam provided 
on June 21, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network medical exam. You say that you should not 
keep getting all these charges for your appointments. 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 $20.14 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20.14 copayment for an out-of-network medical exam. This item/service falls 
within the physician/practitioner services, including doctors office visits 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. You have been asked to pay $20.14 
towards your $11,300 out-of-pocket maximum. Therefore, we decided that the Plan does not have to waive the 
copayment for an out-of-network medical exam provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 08, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
November 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam on tooth #6 (D0364), the pulp vitality test on 
tooth #6 (D0460), the limited oral evaluation (D0140), the intraoral periapical x-ray (D0220), and the bitewing 
x-ray (D0270) provided on February 21, 2022. 
 You asked the Plan to pay for the cone beam on tooth #6 (D0364), the pulp vitality test on tooth #6 (D0460), 
the limited oral evaluation (D0140), the intraoral periapical x-ray (D0220), and the bitewing x-ray (D0270). 
You say that the services were supposed to be covered. You say you should not have a balance. The Plan 
denied your request. The Plan says the cone beam on tooth #6 (D0364) and the pulp vitality test on tooth #6 
(D0460) are not covered benefits. The Plan says your benefit for the limited oral evaluation (D0140) has 
already been exhausted. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam on tooth #6 (D0364) 
and the pulp vitality test on tooth #6 (D0460) are not among those covered under this benefit. The record shows 
your benefit for the limited oral evaluation (D0140) was exhausted on date of service April 26, 2022. You have 
also been asked to pay the difference between the out-of-network providers charges and the Plans payment 
for the intraoral periapical x-ray (D0220) and the bitewing x-ray (D0270). 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 for the cone beam on tooth #6 (D0364), the pulp 
vitality test on tooth #6 (D0460), the limited oral evaluation (D0140), the intraoral periapical x-ray (D0220), 
and the bitewing x-ray (D0270) provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you would like this visit covered because 
the referral was sent by a renowned provider. The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
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 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the provider put the pieces of the broken 
crown back in. You also say that you cannot eat meat on that side of your mouth, because of the jaggedness of 
the crown. 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 October 27, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740).  
 
  Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services were medically necessary 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 an office visit provided 
on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140), electrical stimulation (G0283), 
therapeutic exercises (97110), and the paraffin bath therapy (97018) provided on March 28, 2022. 
 
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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140), electrical stimulation (G0283), therapeutic 
exercises (97110), and the paraffin bath therapy (97018) provided on March 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest the chest x-ray provided on March 19, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the denied claim should be reconsidered with added 
modifier GW. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on March 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest the chest x-
ray provided on March 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite for tooth #22 (D2332/D2331) on 
November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that there was a limit. 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 June 23, 2022. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite for tooth #22 (D2332/D2331) on 
November 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 10, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the Plan needs to reprocess and pay the claim 
according to the enrollee's benefits. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2752) and crown repair necessitated by 
restorative material failure (D2980) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were needed and were causing an 
infection. The Plan denied your request. The Plan says these services are not covered by the Plan's 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 the crown 
(D2752) and crown repair necessitated by restorative material failure (D2980) provided on September 13, 
2022.