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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) and a 
specialist office visit provided on October 20, 2022. 
 
You asked the Plan to waive the copayment for an ECG and a specialist office visit. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for outpatient diagnostic tests/ECG and a $35 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a $30 copayment for an ECG and a $35 copayment for a specialist office visit. The 
total amount you are being asked to pay for the ECG $14.47 which is less than the required amount of $30. The 
total amount you are being asked to pay for both services is $49.47 ($35 +14.47 = $49.47). This item/service falls within the outpatient diagnostic tests/ECG and physician/practitioner services/specialist benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an electrocardiogram (ECG) and a specialist office visit 
provided on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart permanent cardiac contractility 
modulation (CCM) system. 
 
You asked the Plan to pre-approve an Optimizer Smart permanent CCM system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Optimizer Smart permanent CCM 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, a CCM system is not considered to be 
medically necessary in this 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 an Optimizer Smart permanent CCM system have not been met. Therefore, we decided that the Plan does not have to pre-approve an Optimizer Smart permanent cardiac contractility 
modulation (CCM) system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on May
16, 2022.
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says that this claim has been billed with an
incorrect date of service.
The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS)
policy for either a clinical laboratory test or the technical component of physician pathology service is to bill
the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan
requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of
service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state
that the date of service submitted on the claim form must be the date the specimen was collected if the
specimen was collected in a laboratory. The specimen was collected on December 17, 2021, but the date of
service on the claim form was May 16, 2022.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the genetic testing services provided to the enrollee on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0380) 
provided on November 16, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial and the services are medically necessary. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography (CT) scan (D0380) provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a sodium hyaluronate injection provided 
on September 29, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not told there would be a 
cost sharing amount for this 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
You have been asked to pay $150.98, which is 20% coinsurance of the allowed amount for the injection 
($754.90 allowed amount x 20% coinsurance = $150.98). 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 coinsurance for a sodium 
hyaluronate injection provided on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthopedic visit provided on October 03, 2022. 
 
You asked the Plan to pay for an orthopedic visit. You say that you want this to be reviewed again, it should be 
covered. 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 orthopedic visit 
provided on October 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on December 05, 2022. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
The facility is in control of all paperwork and verification. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on December 05, 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 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 office visit provided on 
November 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) provided on October 4, 
2022. 
 
You asked the Plan to pay for the cone beam CT capture. You say that the enrollee had a broken tooth and this 
was an emergency. You also say that this was necessary for the dentist to perform the CT scan. The Plan 
denied your request. The Plan says this service is not covered under the 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 pay for a cone 
beam CT capture (D0364) provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $250 for the acupuncture services (97810) provided
from January 7, 2021, to December 30, 2021.
You asked the Plan to reimburse you $250 for the acupuncture services. You say that you sent all of the
necessary paperwork that was required on March 11, 2022. The Plan denied your request. The Plan says you
did not request reimbursement timely.
Your contract with the Plan clearly says that they reimburse you up to $250 per calendar year towards your cost
of acupuncture and that reimbursement requests must be received by the Plan no later than March 31st of the
following year. The Plan has provided documentation confirmed your reimbursement request was not received
by the Plan until May 13, 2022. This is after the submission deadline for reimbursement of March 31st of the
following year. Therefore, we decided that the Plan does not have to reimburse you $250 for the acupuncture
services (97810) provided from January 7, 2021, to December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth, by report (D4381 x 4), gingival irrigation-per quadrant 
(D4921), and the topical application of fluoride varnish (D1206) provided on October 5, 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 payable. 
 
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, gingival irrigation and the localized 
delivery of antimicrobial agents provided are not among those services covered under this benefit. 
Additionally, the Plan contract states that the topical application of fluoride varnish is covered twice per 
calendar year. You previously received this service on March 9, 2022 and June 9, 2022 accordingly, which 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we 
decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth, by report (D4381 x 4), gingival irrigation-per quadrant 
(D4921), and the topical application of fluoride varnish (D1206), provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of impacted tooth, soft tissue (D7220) for
teeth #'s 1 and 16, the removal of impacted tooth, partially bony (D7230) for teeth #s 17 and 32, and the bone
replacement graft for ridge preservation, per site (D7953).
You asked the Plan to pre-approve these dental services. You say that you are unable to sleep, experiences
headaches, and jaw pain. The Plan denied your request. The Plan says that these services are not a covered
benefit. Maximus partially overturned the Plan's denial based on medical necessity. The Plan requested a
reopening and confirmed this was not a medical necessity denial, but an administrative denial based on these
services not being covered by 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 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 the removal of impacted tooth, soft tissue
(D7220) for teeth #'s 1 and 16, the removal of impacted tooth, partially bony (D7230) for teeth #s 17 and 32,
and the bone replacement graft for ridge preservation, per site (D7953).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 22, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. 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 $255 
copayment for ambulance services. 
 
You have been asked to pay a $255 copayment for ambulance services. This item/service falls within the 
ambulance services 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 ambulance services 
provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (ECG) and a 
specialist office visit provided on September 7, 2022. 
 
You asked the Plan to waive the copayment for ECG and a specialist office visit. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for outpatient diagnostic test/Medicare -covered diagnostic test radiology services and a $45 
copayment for physician/practitioner services/specialist.  
 You have been asked to pay a $125 copayment for ECG and a $45 copayment for a specialist office visit. The 
total amount you are being asked to pay for the ECG is $92.67 which is less than the required amount. The total 
amount you are being asked to pay for all services rendered is $137.67 ($92.67 + $45 = $137.67). This 
item/service falls within the outpatient diagnostic test/Medicare -covered diagnostic test radiology services and 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an echocardiography (ECG) and a specialist office visit provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface posterior (D2391) and 
the intraoral-periapical first radiographic image (D0220) provided on September 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service May 18, 2022. Specifically, the 
Plan contract states that the annual maximum allowable dental benefit is $3,000. The records shows that you 
received dental services on March 12, 2022, April 1, 2022, April 2, 2022, and May 18, 2022. These services 
were paid for by the Plan in the amount of $3,000, which is the maximum amount payable per year.  Therefore, you have exhausted the allowable benefit for these services. Therefore, we decided that the Plan 
does not have to pay for the resin-based composite-one surface posterior (D2391) and the intraoral-periapical 
first radiographic image (D0220) provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, debridement and osseous 
contouring, bone graft (D6102, D4266, D6103) provided on October 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for guided 
tissue regeneration, debridement and osseous contouring, bone graft (D6102, D4266, D6103) provided on 
October 28, 2022.