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

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on September 
22, 2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that the services provided should 
not be considered surgery. 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 $150 
copayment for each in-network Medicare-covered outpatient surgery in a hospital.  
 
According to Medicare, an arthrocentesis is considered a surgical procedure. You have been asked to pay a 
$150 copayment for an arthrocentesis. This item/service falls within the outpatient surgery 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 arthrocentesis provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and intraoral 
x-rays (D0210) provided on October 24, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with denial for the dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service April 29, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
intraoral x-rays (D0210) provided on October 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for MRI's both the cervical spine and the lumbar spine for the enrollee.
You asked the Plan to provide coverage for this imaging. You say that at the time of the appeal, the requested imagining was medically necessary. The Plan denied your request. The Plan says the Medicare criteria for the MRI's requested of the cervical and lumbar spine were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not review the request appropriately.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for MRI imaging without contrast of the cervical spine and the lumbar spine. The enrollee was a then 85-year-old woman with diagnoses of spondylosis with radiculopathy, lumbosacral region, spondylosis with radiculopathy, cervical region, and spinal stenosis, lumbar region with neurogenic claudication. The enrollee was evaluated on December 1, 2022, in a spine and pain management office. Symptoms include a level of 8 out of 10 neck and low back pain. The enrollee has pain into her legs with a neurogenic overlay, and numbness and tingling into her hands. Standing and walking are noted to be problematic. It is documented that the enrollee has not had interventional therapy. The records state home treatment with heat and ice. An addendum dated December 31, 2022 states that the enrollee "has tried this conservative treatment for at least 6 weeks within the last 3 months."
However, there is insufficient medical record documentation of the stated completion of six weeks of provider directed conservative measures, such as medication, physical therapy, and/or oral or injected steroids. Medicare criteria for this imaging were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of either of these services have not been met. Therefore, we decided that the Plan does not have to provide coverage for magnetic resonance imaging (MRI) of both the cervical spine and the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the application of fluoride 
(D1206), gingival irrigation (D4921) and waive the coinsurance for the periodontal maintenance (D4910) 
provided on November 22, 2022. 
 You asked the Plan to pay for and waive the coinsurance for the dental services. You say that you should not be 
charged to pay for services that were not properly done the first time. The Plan denied your request. The Plan 
says the denial of payment for the limited oral evaluation, application of fluoride, and gingival irrigation is 
correct, because they are not covered by the Plan. Also, the cost sharing was charged correctly for the 
periodontal maintenance. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for periodontal 
maintenance. The total amount allowed was $65 with a coinsurance amount of $32.50 ($65 total amount x 50% 
coinsurance). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation, application 
of fluoride, and gingival irrigation are not among those covered under this benefit. You have been asked to pay 
a 50% coinsurance for the periodontal maintenance. This item/service falls within the Dental Services benefit 
category. This means 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 pay for a limited oral evaluation (D0140), the application of fluoride (D1206), 
gingival irrigation (D4921) and waive the coinsurance for the periodontal maintenance (D4910) provided on 
November 22, 2022.  
 
Your complaint about the provider charging you for dental services that were provided 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 limited oral evaluation - problem focused (D0140), 
panoramic radiographic image (D0330), guided tissue regeneration - resorbable barrier, per site (D4266), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210), collection and application of autologous blood concentrate product 
(D7921), bone replacement graft for ridge preservation - per site (D7953), deep sedation/general anesthesia - 
first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), 
and therapeutic parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pay for dental services. You say that you needed to see an oral surgeon, but you could 
not find one in-network. You would like to be reimbursed for the surgery. The Plan denied your request. The 
Plan says these services are not covered under your 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. Limited oral evaluation - 
problem focused, panoramic radiographic image, guided tissue regeneration - resorbable barrier, per site, 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated, collection and application of autologous blood concentrate product, bone 
replacement graft for ridge preservation - per site, deep sedation/general anesthesia - first 15 minutes, deep 
sedation/general anesthesia - each subsequent 15 minute increment, and therapeutic parenteral drugs, two or 
more administrations, different medications. 
 
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 limited 
oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), guided tissue regeneration 
- resorbable barrier, per site (D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210), collection and application of 
autologous blood concentrate product (D7921), bone replacement graft for ridge preservation - per site 
(D7953), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each 
subsequent 15 minute increment (D9223), and therapeutic parenteral drugs, two or more administrations, 
different medications (D9612).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to provide coverage for a Feraheme (ferumoxytol) injection for the enrollee.
You asked the Plan to provide coverage for a Feraheme (ferumoxytol) injection. You say that this drug is
medically necessary. The Plan denied your request. The Plan says that the Medicare coverage criteria were not
met. Maximus upheld the Plans decision. After we made our decision, we reopened the case due to a perceived
error on the review.
Our Medical Director looked at the case file. At issue is coverage for Feraheme (ferumoxytol injection). The
enrollee is a 65-year-old woman with a history of urothelial cancer and development of pulmonary metastatic
disease. The enrollee has stage 3a chronic kidney disease (CKD). There has been progression of the lung
masses, and a recent computed tomography scan revealed a large retroperitoneal mass. On February 2, 2023,
the Hgb was 8.69. On February 20, 2023, the Hgb was 9.329 and the total iron was less than10 mcg/dL (L).
Iron binding capacity was 196 mcg/dL (L), % saturation 5 (L), Ferritin 541 (H), BUN 140 mg/dL (H), and
Creatinine 3.36 (H). Feraheme (ferumoxytol) Injection is indicated for the treatment of iron deficiency anemia
in adult patients with chronic kidney disease (CKD). The enrollee in this case has laboratory studies consistent
with the diagnosis of iron deficiency anemia and chronic kidney disease. In patients with chronic activation of
cell-mediated immunity, such as in malignancy (as this enrollee has), a low iron level and increased ferritin
level are characteristic. Medicare coverage criteria in this case are met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Feraheme (ferumoxytol injection) have been met. Therefore, we decided that
the Plan has to provide coverage for a Feraheme (ferumoxytol) injection for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on May 09, 
2022. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you think that the 
copayment for this service is too high. 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 $200 
copayment for each Medicare-covered surgery, performed at an outpatient hospital facility. 
 
You have been asked to pay a $200 copayment for a facet joint injection. This item/service falls within the each 
Medicare-covered surgery, performed at an outpatient hospital facility 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 a facet joint injection provided on May 09, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
October 15, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not agree with 
the cost sharing applied to 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 a $90 
copayment per emergency room visit within or outside the service area. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 emergency room visit 
provided on October 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 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 June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services are not covered benefits. The Plan 
denied your request. The Plan says you would like to request reconsideration of the denied claim. 
 
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 dental 
services on September 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health visits provided on May 09, 2022, to May 16, 
2022. 
 
You asked the Plan to pay for mental health visits. You say that this was medically necessary and 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 mental health visits 
provided on May 09, 2022, to May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee does not have the option of what 
laboratory service to use. 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 laboratory services 
provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391), and 
prophylaxis - adult (D1110) provided on November 16, 2022. 
 
You asked the Plan to pay for codes D2391 and D1110. You say that you are being overcharged and have 
submitted supporting documentation. The Plan denied your request. The Plan says the services performed are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 resin-
based composite - one surface, posterior (D2391), and prophylaxis - adult (D1110) provided on November 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0210) provided on 
August 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told x-rays were covered with a 50% 
coinsurance. The Plan denied your request. The Plan says the denial of payment for this service is correct 
because intraoral radiographic images are not covered by the Plan. Also, it was verified that the proper 
coverage was told to the enrollee. 
 
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 the 
intraoral radiographic image (D0210) provided on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050 x 2) purchased on 
October 24, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids were purchased 
from an out-of-network provider, without prior authorization. 
 
Medicare generally does not cover dental services. However, the Plan offers a hearing aid benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at this file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that prior authorization rules 
apply to hearing aids purchased from an out-of-network provider. However, prior authorization was not 
obtained from the Plan for the hearing aids purchased in this case. Therefore, we decided that the Plan does not 
have to issue reimbursement for the hearing aids (V5050 x 2) purchased on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the root canal (D3330) for tooth #19 provided by an 
out-of-network provider on October 26, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you were told you can see an out-of-
network provider and you would only be responsible for 50% of the bill. The Plan denied your request. 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. 
 
  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. The 
total allowed amount by the Plan was $767 with a coinsurance of $383.50 ($767 allowed amount x 50% 
coinsurance). The total amount the provider charged was $1,522 leaving the enrollee responsibility between the 
charged amount and allowed amount of $755 ($1,522 charged amount - $767 allowed amount). The total 
enrollee responsibility for the root canal was $1,138.50 ($383.50 coinsurance + $755 difference in amounts). 
Therefore, we decided that the Plan does not have to pay more for the root canal (D3330) for tooth #19 
provided by an out-of-network provider on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on November 29, 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 November 29, 2022.