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

We decided that the Plan does not have to pay for the bone replacement graft (D7953) and prefabricated abutment and placement (D6056) provided on June 28, 2022.
You asked the Plan to pay for these services. You say that these dental services were medically necessary. The Plan denied your request. The Plan says notice was given to your provider prior to the service being rendered that the requested treatment would not be covered. Maximus overturned the Plans denial because the case file lacked required information regarding the denial. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. 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 services provided were not listed as covered under your dental benefit.
In addition, your provider was refused prior authorization for these services. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) and prefabricated abutment and placement (D6056) provided on June 28, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (99214) services billed to the enrollee from May 31, 2022, and June 1, 2022.
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 the Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that the claim identified the service facility and an Emergency location. The clinical notes on both May 31, 2022, and June 1, 2022, identify the providers as a "Hospital Medicine Faculty Service" and included notations that state "Admit to inpatient orders signed". The codes for Evaluation and Management (E&M) Services describe the site of service (e.g., office, hospital, home, nursing facility, emergency department, critical care), the type of service (e.g., new or initial encounter, follow-up or subsequent encounter), and various miscellaneous services (e.g., prolonged physician service, care plan oversight service). Code 99214 excludes services provided in emergency department, hospital observation, or hospital inpatient. There are more appropriate codes and POS codes to describe the services documented in the progress notes.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, based on the records provided, these services were inappropriately billed based on the location of the services rendered. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services billed to the enrollee from May 31, 2022, and June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for repair of the brow ptosis and the repair of blepharoptosis at the in-network rate.
You asked the Plan to provide coverage for out of network services at the in-network rate. The Plan denied your request. The Plan says while the services were approved, there were providers in network who could render this service, and exception for payment at the in-network rate was not warranted. Maximus overturned the Plans denial stating the requested services were medically appropriate. The Plan requested a reopen and stated that the services were approved, the only issue was the out of network cost share exception requested.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract allows the use of out of network providers at a higher rate. The Plan has shown there were network providers available that can render this service. Therefore, we decided that the Plan does not have to provide coverage for this service at the in-network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit (99204).
You asked the Plan to pre-approve a chiropractic office visit. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. Maximus overturned the Plan's denial. The Plan requested a reopening based on the fact that office visits for chiropractic care is not covered by Medicare. The Plan is correct in this case. These services are being requested to treat spondylosis, which is not a covered service. Chiropractic care (manual manipulation) is only covered to treat subluxation. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a chiropractic office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a chiropractic office visit (99204).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Claim A.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient explanation of the claim issue. The Plan requested a reopen and demonstrated that this claim denied because the Plan received this claim past the allowed 12-month timeframe. The records show the Plan originally received the original claim on October 20, 2020, which was denied for lacking prior authorization. A corrected claim was submitted on May 12, 2022; however, the submission was past the allowed 12-month timeframe. The Plan provided the original and corrected claims that show the receive dates.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must submit claims within the required timeframes. This included corrected claims. In this case, the Plan has demonstrated that the correct submission was not timely.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Claim A.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for specialist services, radiological
diagnostic services and diagnostic injection services provided to the enrollee from February 2, 2022 to August
5, 2022.
You asked the Plan to waive this cost share. You say that the enrollee does not believe this cost share is correct.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus upheld the Plans
denial but listed the incorrect service in dispute. Maximus reopen the appeal and correct the decision review.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay cost share for each outpatient service provided. The Plan provided medical records and the Medicare
allowed cost for each of the services provided. The enrollee has been asked to pay the correct amount based on
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share charged for
specialist services, radiological diagnostic services and diagnostic injection services provided to the enrollee
from February 2, 2022, to August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture (D6740) for teeth #6 and 8, a retainer (D6245) for tooth #7, core buildups (D2950) for teeth #9, 10 and 11 and crowns (D2740) for teeth #9 and 11.
You asked the Plan to pre-approve these services. You say that the treatment provided was the correct and best treatment for the enrollee. The Plan denied your request. The Plan says these services are not necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan covers these services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee. The crowns or a fixed bridge for teeth #6, #8, #9, and #11 are not medically necessary as there is sufficient structure to allow for conventional restorations. The treatment plan for a bridge is a possible alternate treatment plan after the removal of tooth #7, though not medically necessary. A removable appliance or implant could also be utilized to fill the missing space as alternatives. Teeth #6, #8, #9 and #11 do not have four or more involved surfaces along with 50% or more incisal damage and would therefore not qualify for a crown. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a fixed partial denture (D6740) for teeth #6 and 8, a retainer (D6245) for tooth #7, core buildups (D2950) for teeth #9, 10 and 11 and crowns (D2740) for teeth #9 and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2331, D2332, D2391, and D2392), 
gingival flap procedure (D4241), bone replacement graft (D4263), guided tissue regeneration (D4266), and 
extractions (D7140) for tooth #10, #11, #12, #19, #20, #27, #29, #30 provided by an out-of-network provider 
on April 27, 2022, May 4, 2022, May 9, 2022, May 23, 2022, June 8, 2022, and September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should have covered more of the dental 
procedures. The Plan denied your request. The Plan says your benefit for the resin-based composites has already been exhausted. Also, the denial of payment for the gingival flap procedure, bone replacement graft, 
guided tissue regeneration, and extractions is correct because they are 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, certain limitations apply. The record 
shows your benefit for the resin-based composites was exhausted on the date of service of May 23, 2022. The 
gingival flap procedure, bone replacement graft, guided tissue regeneration, and extractions are not covered 
under the Plans dental benefit. You have been asked to pay the difference between the out-of-network 
providers charges and the Plans payment. 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 resin-based 
composites (D2331, D2332, D2391, and D2392), gingival flap procedure (D4241), bone replacement graft 
(D4263), guided tissue regeneration (D4266), and extractions (D7140) for tooth #10, #11, #12, #19, #20, #27, 
#29, #30 provided by an out-of-network provider on April 27, 2022, May 4, 2022, May 9, 2022, May 23, 2022, 
June 8, 2022, and September 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the aminolevulinic acid topical solution 
provided by an in-network provider on November 9, 2022. 
 
You asked the Plan to waive the cost sharing for the topical solution. You say that you do not understand the 
cost sharing applied to this item/service. 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% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer. 
 
 
 
 
 You have been asked to pay a $78.42 coinsurance for the topical solution ($392.09 allowed amount x .20 = 
$78.42 rounded up). This item/service falls within the Medicare Part B prescription drugs 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 cost sharing for the aminolevulinic acid topical solution provided by an in-
network provider on November 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the home infusion therapy services 
provided by an in-network provider from March 10, 2021, to May 4, 2021. 
 
You asked the Plan to waive the copayment for the home infusion therapy services. You say that you do not 
understand why you are being billed for these services. 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 in-network Medicare-covered home infusion therapy professional services, training and 
education, and monitoring. 
 
 
 
 You have been asked to pay a $1960 copayment for the home infusion therapy services ($35 x 56 services = 
$1960). These items/services fall within the home infusion therapy 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 home infusion therapy services provided by an in-network provider from March 
10, 2021, to May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the 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 the laboratory services 
provided on April 26, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 19, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior 
(D2394) and core buildup, including any pins when required (D2950) x2 provided on November 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the core build up is 
not covered when required and you do not agree with the limitation rule. 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. This benefit includes the 
requested resin-based composite - four or more surfaces, posterior (D2394) but is limited to two procedure 
coders per calendar year. Core buildup, including any pins when required (D2950) is not covered under the 
Plans dental benefits. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered resin-based 
composite-four or more surfaces (D2335) on February 8, 2022, and July 16, 2021, and received covered resin-
based composite-four or more surfaces (D2335) on February 15, 2022. Although these are two different 
services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, these benefits were exhausted as of February 15, 2022. Also, the requested 
D2950 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for resin-based composite - four or more surfaces, posterior (D2394) and core buildup, including any pins when 
required (D2950) x2 provided on November 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 04, 2022. 
 
You asked the Plan to pay for the office visit. You say that the authorization request was missed for this claim. 
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 office visit provided 
on November 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient surgery provided on July 03, 2022. 
 
You asked the Plan to pay for inpatient surgery. 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 inpatient surgery 
provided on July 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, intraoral 
periapical x-rays, prophylaxis, and adjunctive pre-diagnostic test provided on December 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that these services should have been paid by the 
Plan, and you would like this claim to be reconsidered. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
The Plan also says that you did not reach out to the Plan to verify benefits or contract status. 
 
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 periodic oral evaluation, bitewing x-rays, intraoral periapical x-rays, prophylaxis, and adjunctive 
pre-diagnostic test provided on December 2, 2022, by an out-of-network (OON) provider.