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

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on December 29, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told you wouldn't have to 
pay a thing for the scan. The Plan denied your request. The Plan says the copayment was applied 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 $150 
copayment for CT scans when in-network.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 the CT scan provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on May 3, 2021,
coded as J2001.
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 coding edit prevents this claim from payment. Maximus overturned the Plans denial.
The Plan requested a reopen and provided a copy of the American Medical Association coding guidelines to
show that code J2001 was a column two code edit to code 20610, a column 1 code. This PTP edit also shows a
modifier indicator of "1", meaning modifiers associated with NCCI are allowed. However, the Plan notes an
appropriate modifier was not billed on this claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim cannot be paid as billed due to the omission of the required
modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for injection services provided to the enrollee on May 3, 2021, coded as J2001.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220 and D0230) and the periodontal 
maintenance (D4910) provided on March 14, 2022. 
 
You asked the Plan to pay for dental codes D0220, D0230, and D4910. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0220, D0230, 
and D4910 are not covered services under the Plan's supplemental 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, dental codes D0220, D0230, and 
D4910 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-rays (D0220 and D0230) and the periodontal maintenance (D4910) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy of oral tissue (D7286) inhalation of nitrous oxide 
(D9230) provided January 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had oral surgery to extract two teeth and 
removal of a growth on your tongue. The Plan denied your request. The Plan says these services are not 
covered under the Plan 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 biopsy of 
oral tissue (D7286) inhalation of nitrous oxide (D9230) provided January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation treatment, extra-spinal regions 
(98943) electrical stimulation (G0283) provided December 29, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the documentation supports the medical 
necessity provided to the enrollee. Please consider reprocessing of the previously denied claim based on the 
additional information submitted. The Plan denied your request. The Plan says these services are not covered 
when rendered by a chiropractor. 
 
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 chiropractic manipulation treatment, extra-spinal regions (98943) electrical 
stimulation (G0283) provided December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided August 13, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that this service was medically necessary, and 
you expected it to be covered. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body: endosteal implant (D6010) provided August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider had consulted the Plan and gave 
you an estimate of $487 to be billed to you. Based on this information you agreed to have the crown work done 
instead of a filling. You contacted the provider and they admitted their mistake. The Plan denied your request. 
The Plan says this service is not covered under the Plan benefits. 
 
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 
porcelain/ceramic crown (D2740) provided January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided 
December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you received this dental bill for $276. You were 
told that only one part of this procedure was paid. This is too much to pay you are on a fixed income. The Plan 
denied your request. The Plan says the benefits frequency limitation 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. The health Plan contract says 
that once procedure code for periodontal scaling and root planing is covered every three years. The records 
show that you received periodontal scaling and root planing on 02/16/2019, therefore the benefit has been 
exhausted.  
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 
periodontal scaling and root planing (D4342) provided December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
crown - porcelain/ceramic (D2740), and endodontic therapy, premolar tooth (excluding final restoration) 
(D3320) provided January 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the core buildup, crown and root canal. You say that the provider contacted the 
Plan to verify coverage the day before. The Plan denied your request. The Plan says these services are not 
covered when provided OON. Additionally, the Plan says they reviewed the history of call requests regarding 
your benefit coverage and did not find any calls verifying coverage from you or the 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. The Plan covers the core 
buildup, crown and root canal when provided in-network.   
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the core buildup, crown and root canal have not been met. Therefore, we decided that the Plan does not have to 
pay for the core buildup, including any pins when required (D2950), crown - porcelain/ceramic (D2740), and 
endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided January 11, 2022, by an out-
of-network (OON) provider.  
 
Your complaint about potentially being provided misinformation by a plan representative 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for problem focused oral exam (D0140) intraoral, periapical first 
x-rays (D0220) provided January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been misled by the Plan's agent on 
your dental coverage. The Plan denied your request. The Plan says this service is not covered when rendered by 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for problem 
focused oral exam (D0140) intraoral, periapical first x-rays (D0220) provided January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical extraction (D7210) Bone replacement graft for ridge 
preservation (D7953) provided January 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the fact that the doctor 
was not in the Plan's network. Since it is a surgical procedure you thought at worse that it would be covered by 
out of network reimbursement terms. The Plan denied your request. The Plan says these services are not 
covered under the Plan benefits. 
 
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 surgical 
extraction (D7210) Bone replacement graft for ridge preservation (D7953) provided January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental consultation (D9310) administration of nitrous 
oxide (D9230) intraoral, complete series x-rays (D0210) surgical removal of erupted tooth (D7210) Periodontal 
Scaling and Root-Planing (D4341) provided December 6, 2021 to December 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that before you proceeded with the treatment you 
spoke with Plan representatives, and it was not explained to you not to see any licensed dentist outside the 
network. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate 
in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except in 
cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
consultation (D9310) administration of nitrous oxide (D9230) intraoral, complete series x-rays (D0210) 
surgical removal of erupted tooth (D7210) Periodontal Scaling and Root-Planing (D4341) provided December 
6, 2021 to December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar (excluding final restoration) 
(D3330) unspecified endodontic procedure (D3999) unspecified preventive procedure (D1999) provided 
December 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that the office staff verified coverage when you 
scheduled the appointment. You cannot pay for this and shouldn't have to pay it when the Plan told you it was 
covered and paid the claim then waited a year to reverse the claim. The Plan denied your request. The Plan says 
if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of 
the services you receive. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy, molar (excluding final restoration) (D3330) unspecified endodontic procedure (D3999) 
unspecified preventive procedure (D1999) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on March 26, 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 covered.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 the special 
anesthesia service rendered on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral/facial photographic image (code D0350) you 
received from your dentist on February 8, 2022. 
 
You asked the Plan to pay for the oral/facial photographic image (code D0350). You say that you believe this is 
a covered service. The Plan denied your request. The Plan says this service is not covered under 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 Plan's coverage rules apply in this case. The Plan's dental benefit 
includes coverage only for those dental services explicitly listed in your Plan Schedule of Benefits. The 
oral/facial photographic image (code D0350) is not listed as a covered service. 
 
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 
oral/facial photographic image (code D0350) you received from your dentist on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on 
December 22, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you went to the dentist on this date with a 
painful tooth.  You said that you had an earlier problem with another tooth, so this should be covered. The Plan 
denied your request. The Plan says you had already exhausted this benefit and were not eligible for coverage of 
this service. 
 
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. Your Plan contract says that 
your dental benefit includes coverage of limited oral exams (code D0140) once per plan year.  You already had 
a covered limited oral exam on December 9, 2021.  This benefit limitation exists even if the exams are related 
to different teeth. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral exam (code D0140) you received on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on January 
25, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that the dentist could not perform the extraction 
procedure without an exam first. The Plan denied your request. The Plan says this service is not covered under 
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 Plans coverage rules apply in this case. The Plan's dental benefit is 
limited and only covers certain services.  Limited oral exams are not listed as covered dental services in your 
benefits chart. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral exam is not among 
those covered under this benefit. This service is not covered for any reason. Therefore, we decided that the Plan 
does not have to pay for the limited oral exam (code D0140) you received on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction you had on December 14, 2021, from an 
out-of-network dentist. 
 
You asked the Plan to pay for the out-of-network dental extraction. You say that you were told that this was a 
network provider and this would be covered. The Plan denied your request. The Plan says they have no records 
of you calling them on December 10, 2021.  There is a record of you calling the Plan on December 13, 2021, 
but you were not given this provider's name on that call. The Plan says that out-of-network dental care is 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. Your Plan does not cover 
dental services provided by an out-of-network dentist. 
 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 
extraction you had on December 14, 2021, from an out-of-network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested bone marrow aspirate 
(20939) is medically necessary. The Plan denied your request. The Plan says the requested bone marrow 
aspirate (20939) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate (20939) is not medically necessary. Our physician reviewer found 
bone marrow aspirate is experimental. More research is needed to show safety and efficacy. At this time, bone 
marrow aspirate is not medically necessary. 
 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate (20939).