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

 
We decided that the Plan does not have to pay for an immediate maxillary denture (D5130) and an implant 
supported removable denture (D6111) provided on July 19, 2022, and alveoloplasty (D7310), extractions 
(D7140, D7210), endosteal implants (D6010), and bone grafts (D6104) provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were misled to believe you would pay $80 a 
month to receive the $2,000 reimbursement for dental services. The Plan denied your request. The Plan says 
that an immediate maxillary denture (D5130), an implant supported removable denture (D6111), alveoloplasty 
(D7310), extractions (D7140, D7210), endosteal implants (D6010), and bone grafts (D6104) are not covered by 
your supplemental 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 an 
immediate maxillary denture (D5130) and an implant supported removable denture (D6111) provided on July 
19, 2022, and alveoloplasty (D7310), extractions (D7140, D7210), endosteal implants (D6010), and bone grafts 
(D6104) provided on July 20, 2022.  
 
Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Kansas City CMS Regional Office so that it can look into your enrollment question.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux for the enrollee.
You asked the Plan to pre-approve Erbitux. You say that this is the enrollee's last treatment option. The Plan denied your request. The Plan says that the requested drug/regimen is not being prescribed for a supported medically accepted indication.
Our Medical director looked at the case file and the reopen request. At issues is coverage for Erbitux. Our Medical Director states that Erbitux is not FDA-approved for the enrollee's diagnosis. There is insufficient support for the use of Erbitux for the treatment of metastatic anal cancer in the major drug compendia or in clinical research appearing in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Erbitux.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 5, 2022.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office or meaning the independent laboratory taking a sample in its laboratory shows "81" as place of service. However, the medical records show the specimen was collected during an outpatient encounter, which is not POS code 81.
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, this claim was not submitted with an appropriate POS code. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional dental filling (D2392) provided on October 24, 
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 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 24, 2022. 
Therefore, we decided that the Plan does not have to pay for an additional dental filling (D2392) provided on 
October 24, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were asked to pay an 
incorrect amount for cost sharing due to a coding issue. 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 $10 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $10 copayment for a specialist office visit. This item/service falls within the 
Medicare-covered specialist visit 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 
specialist office visit provided on December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service September 
19, 2022, to September 22, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97010 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service September 19, 2022, to September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra pairs of lenses and frames provided on September 16, 
2022. 
 
You asked the Plan to pay for extra pairs of lenses and frames. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the maximum benefit has been exhausted.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $240 combined allowance for eyeglasses or contact lenses every 24 months. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $240 combined allowance 
for eyeglasses or contact lenses every 24 months. The record shows this benefit was exhausted on September 
16, 2022. Based on this information, we decided that the Plan's rules for coverage of extra pairs of lenses and 
frames have not been met. Therefore, we decided that the Plan does not have to pay for extra pairs of lenses 
and frames provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital service provided on October 06, 2022. 
 
You asked the Plan to pay for an outpatient hospital service. You say that the records attached support the 
services provided. 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 outpatient hospital 
service provided on October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on August 11, 2022, to 
August 25, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you go to this provider since they are 
close to home and you have used them before. 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 chiropractic services 
provided on August 11, 2022, to August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for drug testing (80307) provided to the enrollee on May 11, 2022.
You asked the Plan to pay for these services. You say that this testing 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 information in the case file. The Plan requested a reopen and provided additional
information. The Plan demonstrated that based on the code descriptions and the Medicare guidelines, only one
drug test is allowed within the presumptive drug class and one drug test within the definitive drug class per date
of service for an enrollee by the same or different provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim cannot be paid as billed due to a similar billing for the same
enrollee for the same drug class. Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for drug testing (80307) provided to the enrollee on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on September 1, 
2022. 
 
You asked the Plan to pay for an oxygen concentrator. You say that you disagree with the denial and ask for 
reconsideration. You also say according to your review there is only a total of twenty-two payments, not thirty-
six. The Plan denied your request. The Plan says reimbursement for oxygen equipment is limited to 36 monthly 
rental payments. The Plan also says payments have been made since 2019, 2020 till current date. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. The records show that payments have been made since 2019, 2020, 
till the current date, per the rental cap sheet, a total of 37 payments have been made. The enrollee has reached 
the total reimbursement allowed for oxygen equipment. Based on this information, we decided that Medicare 
rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pay for an oxygen concentrator (E1390) provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were unable to obtain authorization due to a 
short time period. 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 office visit provided 
on September 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for Irinotecan injections (J9206) provided from May 26, 2022, to July 7, 2022.
You asked the Plan to pay for Irinotecan injections (J9206). You say that these injections were medically necessary. The Plan denied your request. The Plan says your physician was previously told that the Medicare coverage criteria for these injections were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 pay for Irinotecan injections (J9206). The records show you have a diagnosis of metastatic small cell carcinoma of the lung. Irinotecan injections are not FDA-approved for the presented diagnosis. The documentation does not indicate that the use of Irinotecan HCl is supported by one of the major drug compendia or by clinical research that appears in a Medicare approved medical journal.
In addition, the documentation does not support that the requested drug is reasonably expected to be safe and effective and otherwise reasonable and necessary in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Irinotecan injections (J9206) have not been met. Therefore, we decided that the Plan does not have to pay for Irinotecan injections (J9206) provided from May 26, 2022, to July 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 28, 2022, to June 
29, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are requesting a reconsideration for the 
denied payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for inpatient hospital care provided from June 28, 2022, to June 
29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incomplete endodontic therapy (D3332) provided on July 
14, 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 an 
incomplete endodontic therapy (D3332) provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown repair services (D2980) provided on October 24, 
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 n 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 crown 
repair services (D2980) provided on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 14, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $345 
copayment for outpatient surgery/Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $345 copayment for an outpatient surgery. However, you are only being asked to 
pay $295 which is less than the required amount. This item/service falls within the outpatient 
surgery/Medicare-covered outpatient hospital facility visit 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 outpatient surgery provided on July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
December 5, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you do not 
understand why you are being charged a copayment when both services are preventive tests. 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 $75 
copayment for in-network mammography outpatient hospital and $95 copayment for in-network basic 
radiological services outpatient hospital.  
 
  You have been asked to pay $95 for the outpatient hospital services ($75 + $20 = $95). The outpatient hospital 
services falls within the diagnostic mammography and basic radiological services benefit category. You were 
billed the standard $75 copayment for the diagnostic mammography and $20 copayment, which is less than the 
standard $95 copayment for radiological services. 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 outpatient hospital services provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 11, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) provided on 
October 26, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (ECG). You say that this test should be 
routine. 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 $75 
copayment for diagnostic procedures and tests. 
 
You have been asked to pay a $75 copayment for the electrocardiogram (ECG). This item/service falls within 
the diagnostic procedures and tests 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 electrocardiogram (ECG) provided on October 26, 2022.