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

We decided the Plan does not have to pay for a comprehensive oral exam (D0150) provided on April 3, 2021.
You asked the Plan to pay for this service. You say that this dental service should be covered by the Plan. The
Plan denied your request. The Plan says this benefit was covered in 2020 and is only covered every three years.
Maximus overturned the Plans denial as proof of payment for this type of exam in 2020 had not been provided.
The Plan requested a reopen and provided proof of payment for code D0150 for date of service January 30,
2020.
The Plans 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, payment for this exam was made in
2020 and therefore would not be available again until 2023, passed on the Plan coverage rules. Therefore, we
decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for diagnostic vision services provided
on June 17, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
contract language. The Plan demonstrated that the provider submitted a claim for eye exam and refraction
which processed with a $67.27 payment to the provider and a $38.51 member cost share. The Explanation of
Benefits shows a member liability of $18.51 for code 92014 defined as ophthalmological medical examination
and evaluation and $20 for code 92015 defined as the determination of refractive state. These services were
billed as a diagnostic service with a medical diagnosis H35.3131 defined as non-exudative age-related macular
degeneration, bilateral, early dry stage.
This was billed by the provider as a medical procedure and was processed under the medical vision benefit.
The Evidence of Coverage shows for Medicare Covered Vision Services a Specialist Office Visit will have a
$45 copayment on page 90. In this case only a $40 copayment has been charged, which is less than the
contractual copayment expectation.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a $45 copayment for
specialist services. In this case you were charged less than the normal copayment. 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 share charged for diagnostic vision services provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for to pay for lab services provided to the enrollee on July 26, 2021.
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 stating
the decision rational was incomplete. The Plan requested a reopen and explained that denied because the
provider billed this service inappropriately. The Plan has determined these services were coded incorrectly.
This is a billing error on the part of the provider and the service is not reimbursable.
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 there are
discrepancies between the claim submitted and the medical records regarding the dates and times of service in
which these services were rendered. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for to pay for lab services provided to the enrollee on
July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided to the
enrollee on April 12, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this code was previously paid. Maximus overturned the Plans denial for lack of proof of
payment. The Plan requested a reopen and provided proof of payment for code 99239 made on April 29, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code. In this case, the Plan provided documentation to show
this code was previously paid. Medicare rules for coverage of this claim have not been met. Therefore, we
decided that the Plan does not have to pay for hospital discharge day management (99239) provided to the
enrollee on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for outpatient hospital services provided on March 16, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. You say that the Medicare
data shows that the enrollee was not in a skilled nursing facility (SNF) stay on this date of service The Plan
denied your request. The Plan says The Plan says that per the authorization history, the enrollee was discharged
from the hospital on March 12, 2021, and admitted to the SNF. Payment for all services during a covered SNF
stay must be billed and paid by the SNF. Maximus overturned the Plans decision for lack of claim in formation
in the file to support their denial. The Plan requested a reopen and provided additional documentation.
The Plan says that the appeals is for the denial of the post-service claim for procedure codes 93308, 93321 and
93971 (outpatient hospital diagnostic services) provided on March 16, 2021. Per the authorization history, the
enrollee was an inpatient stay at a medical center from February 27, 2021, to March 12,
2021 and then got admitted to a SNF from March 12, 2021, to March 25, 2021. When these services were
rendered, on March 16, 2021, the enrollee was in the SNF. Payment for these services would fall under the
facilities consolidated billing.
The Plan submitted a copy of the claim from the SNF for dates of service March 12, 2021, to March 25, 2021,
and proof of payment by the Plan on May 4, 2021.
The Plan is correct in this case. Medicare rules say that Medicare does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services
to the beneficiary either directly or under arrangements made with outside providers. Payment for this service
would have been included under the facility claim. Payment to you for this service is the responsibility of the
facility. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to
the enrollee on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the multiplex testing of 3-5 targets (87631), as well as 13
other individual pathogens (87486, 87496, 87498, 87541, 87581, 87640, 87798X6, and 87532) provided on
March 5, 2021.
You asked the Plan to pay for any of these services. You say that this claim should be paid. The Plan denied
your request. The Plan says while codes U0003 and U0005 were paid, the remaining codes do not meet
Medicare billing criteria. Maximus overturned the Plans denial because the case record did not contain proof of
payment for codes U0003 and U0005. The Plan requested a reopen and provided proof of payment for these
codes.
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 code. Medicare rules say that PCR
panels of 6 or more panels are not covered, though panels of 3-5 may be covered only when the criteria in the
Medicare rules section are met. Code 87631 is for payment of the first five pathogens tested. However, the
documentation supports that this sample was taken in an assisted living facility, meaning it was not ordered that
is equipped to care for critically ill patients, nor was it ordered by an infectious disease specialist.
As for the remaining codes, these represent tests for pathogens in excess of the 5 covered per Medicare policy.
Therefore, we decided that the Plan does not have to pay for the remaining codes. As stated, prior the Plan has
provided documentation to show code U0003 and U0005 were paid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $55 copayment for physician services provided out of
network on July 26, 2021.
You asked the Plan to waive this copayment. You say that you do not believe his copayment is correct. The
Plan denied your request. The Plan says this copayment was applied based on the Plan contract agreement.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct contract language.
The Plan says that this claim processed with a payment of $371 to the provider. The Plan states the Evidence of
Coverage explains that if you use an out-of-network provider, your share of the costs for your covered services
may be higher and that you may be balance billed for out-of-network. You used an out of network vision
provider. This provider charged $130 of which the Plan paid the allowance of $75. This left a balance owed by
you of $55.
The Plan is correct in this case. 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 any balance over $75 for out of network vision services. 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
$55 copayment for physician services provided out of network on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implants (D6010 x 2), bone replacement grafts 
(D4263 x 2), and cone beam computed tomography (CT) (D0383) provided from August 26, 2021, to October 
22, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services 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 endosteal implants, bone replacement grafts, and cone beam CT are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the endosteal implants (D6010 x 2), bone replacement grafts (D4263 x 2), 
and cone beam computed tomography (CT) (D0383) provided from August 26, 2021, to October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7230) provided on 
February 11, 2022. 
 
You asked the Plan to pay for the removal of an impacted tooth. You say that your dentist recommended this 
surgery. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. The Plan also says that you contacted the Plan prior to this date of service and no inaccurate information 
was provided. 
 
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 
removal of an impacted tooth (D7230) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you have been to the same dentist since you were 
16. You say that you do not want to see an in-network provider. The Plan denied your request. The Plan says 
services provided out-of-network 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. The Plan covers dental 
services when the services are provided out-of-network. 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87801 and 87150) provided on 
November 4, 2021. You asked the Plan to pay for the laboratory services (87801 and 87150). 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 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory services (87801 and 87150) 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 the laboratory services (87801 and 87150) 
provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic images (D0350 x 4), panoramic x-ray 
(D0330), cone beam computed tomography (CT) (D0367), inlay (D2620), oral hygiene instruction (D1330), 
unspecified periodontal service (D4999 x 2), fluoride varnish (D1206), at home drugs (D9630), and scaling and 
root planing (D4342 x 4) provided on October 6, 2021. 
 
You asked the Plan to pay for the panoramic x-ray, 2D images, cone beam CT, inlay, oral hygiene instruction, 
periodontal services, fluoride varnish, and at home drugs. You say that when you signed up for this plan you confirmed that the provider you wanted to use was in network. You say that you confirmed that the services 
would be covered. You also say you did everything you were supposed to do. The Plan denied your request. 
The Plan says the 2D images, cone beam CT, inlay, oral hygiene instruction, periodontal services, fluoride 
varnish, and at home drugs 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 and panoramic x-ray is listed as 
covered once every 5 years, this service shares a frequency limit of once per 5 years with complete series x-ray. 
The record shows that the Plan paid for the complete series x-ray that you received on the date of service in this 
case. Additionally, the 2D images, cone beam CT, inlay, oral hygiene instruction, periodontal services, fluoride 
varnish, and at home drugs are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the 2D photographic images (D0350 x 4), panoramic x-ray (D0330), cone beam 
computed tomography (CT) (D0367), inlay (D2620), oral hygiene instruction (D1330), unspecified periodontal 
service (D4999 x 2), fluoride varnish (D1206), at home drugs (D9630), and scaling and root planing (D4342 x 
4) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials (D4265) and debridement/osseous 
contouring (D6102) provided by an out-of-network provider on October 29, 2021. 
 
You asked the Plan to pay for biologic materials and debridement/osseous contouring. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the rendered services have been 
correctly denied. 
 
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 biologic materials (D4265) and debridement/osseous contouring (D6102) provided by a participating provider on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a complete mandibular denture (D1520).
You asked the Plan to provide coverage for a complete mandibular denture (D1520). You say that the
requested denture is medically necessary. The Plan denied your request. The Plan says you were provided with
a denture in 2019 and this benefit would not be available until 2024. Maximus overturned the Plans denial
stating proof of payment for a denture in 2019 had not been provided. The Plan requested a reopen and
provided the required proof of payment showing they covered a denture provided on May 2, 2019.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for a denture was not
available at the time of the request. Therefore, we decided that the Plan does not have to pre-approve a
complete mandibular denture (D1520).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) provided by a participating provider on 
November 10, 2021. 
 
You asked the Plan to pay for a crown. You say that your wife had the same service done and she did not have 
to pay this much. The Plan denied your request. The Plan says services provided out-of-network 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. The Plan covers a crown when 
the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2750) provided by a participating provider on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two simple extractions (D7140 x2), two surgical 
extractions (D7210 x2), and oral surgery procedure (D7999) provided on September 24, 2021. 
 
You asked the Plan to pay for the extractions and oral surgery procedure. You say that these services were 
rendered because you had 2 teeth which were infected, and you believe should be covered. You also say that 
since receiving these services, you contacted the Plan and were advised that the surgery should be covered 
under your medical plan. The Plan denied your request. The Plan says there is no coverage for oral surgery, and 
this claim processed correctly. 
 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 two 
simple extractions (D7140 x2), two surgical extractions (D7210 x2), and oral surgery procedure (D7999) 
provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on January 17, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you do not understand why this is not 
covered. The Plan denied your request. The Plan says the service provided has been correctly denied. 
 
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 limited 
oral evaluation (D0140) provided by a participating provider on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom abutment (D6057) and abutment supported crown 
(D6059) provided on February 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that crowns are covered. You also say that you do 
not understand why this is not covered. The Plan denied your request. The Plan says abutments that support 
partial removable prosthesis, fixed prosthesis, crowns and all other components are excluded from coverage. 
 
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 custom abutments and abutment 
supported crown are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the custom abutment (D6057) and abutment supported crown (D6059) 
provided on February 4, 2022.