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

We decided the Plan does not have to pay for items submitted towards your flex benefit account on July 2,
2021.
You asked the Plan to pay for these items. You say that the Plan should pay for these items. The Plan denied
your request. The Plan says some of the items claimed are not properly documented and/or not eligible for
reimbursement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not apply the correct contract language. The Plan states that the criteria for reimbursement for the items
were not met because the remaining balance was of $12.28 after the benefits were applied and the there was
no documentation showing if the balance was paid or how it was paid. In addition, even if the balance was paid
using benefits, this would not be eligible for reimbursement because the Flex benefit is to be used to
cover out-of-pocket costs. An out-of-pocket cost can be defined as "having lost money in a transaction" or "(of
an expense or cost) paid for directly rather than being put on account or charged to some other person or
organization." If the items in question were covered by a different government benefit or a coupon, then they
would not be a direct out-of-pocket cost and could not be reimbursed. The receipt does not show payment
method for service received/item purchased.
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). The Plan contract and the claim
form are clear on the requirements for reimbursement.
Food stamps, coupons or alternate government subsidies are already considered a benefit and do not require
direct out of pocket expenses for these items. The documentation submitted for reimbursement was not clear.
Therefore, we decided that the Plan does not have to pay for items submitted towards your flex benefit account
on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for SNF services. You say that at the time of the appeal, SNF services
were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met for transfer from one facility to another. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined you did have documented skilled therapy needs and you were
making progress at the Inpatient Rehabilitation Facility (IRF). The documentation did not yet show that you
had reached a plateau in function. It was determined that ongoing daily skilled services were reasonably
required to establish a maintenance program or to prevent deterioration. The Plan requested a reopen and
argues that the enrollee could have completed care in the IRF to be able to be discharged to the home or
community-based environment. The Plan is correct in this case. The request did not meet Medicare guidelines,
as the enrollee was receiving adequate and necessary care in the Inpatient Rehabilitation Facility. The
documentation does not support that transfer to a SNF was medically reasonable and necessary for the enrollee
in this case. Medicare coverage criteria 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a white glass crown (D2751).
You asked the Plan to provide coverage for a while glass crown. The Plan denied your request. The Plan says
while the partial denture was covered, the records submitted by your provider do not show a crown is
necessary. Maximus administratively overturned the Plans denial because the dental contract had not been
submitted for review. The Plan requested a reopen and provided the required contract.
The Plan is correct in this case. Medicare does not cover dental services. The Plan covers crowns demonstrated
to be reasonable and necessary. Though the Plan offers a dental benefit in excess of Medicare coverage, the
records provided are insufficient to show a crown was necessary. Therefore, we decided that the Plan does not
have to pre-approve a white glass crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain fused to predominantly base metal 
(D6241), retainer crowns - porcelain fused to predominantly base metal (D6751) and extraction, erupted tooth 
or exposed root (elevation and/or forceps removal) (D7140) provided January 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you had a health and dental emergency and 
were not provided any network providers to use. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the pontic - porcelain fused to predominantly base metal (D6241), retainer crowns - porcelain fused 
to predominantly base metal (D6751) and extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140) provided January 5, 2022, by an out-of-network (OON) provider.  
 
Your complaints about issues with customer service and the scarcity of network dentists in your area are not 
valid appeals 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) 
provided on June 12, 2021. 
 
You asked the Plan to pay for code A0422. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for the 
ambulance oxygen and oxygen supplies (A0422) provided on June 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that 8 additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says medical criteria for additional PT has not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the documentation 
does not reveal that the enrollee's requires the unique skills of a professional therapist to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under 
the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on February 2, 
2022, and a limited oral evaluation (D0140) provided on February 4, 2022. 
 
You asked the Plan to pay for the x-rays and evaluation. You say that these dental services are medically 
necessary. The Plan denied your request. The Plan says periapical x-rays (D0220, D0230) and a limited oral 
evaluation (D0140) are not covered by 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 periapical 
x-rays (D0220, D0230) provided on February 2, 2022, and a limited oral evaluation (D0140) provided on 
February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization per site (CPT code D7922 x4) and alveoloplasty in conjunction with extractions 
(CPT code D7311). 
 
You asked the Plan to pre-approve the dental services. You say that you took the health plan because it covered 
dentures, but you did not know that it does not cover all the other things necessary for this work to be done. 
The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve placement of 
intra-socket biological dressing to aid in hemostasis or clot stabilization per site (CPT code D7922 x4) and 
alveoloplasty in conjunction with extractions (CPT code D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) and immediate 
denture - mandibular (D5140) provided March 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not told about OON coverage. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided 
March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening panel identified 
with code 81404 provided on May 10, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening panel. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the type of cardiac risk assessment provided is not covered. This means that the 
cardiac risk assessment genetic screening panel at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the cardiac risk assessment genetic screening panel identified with code 81404 
provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (code D0150) and complete series of  
images (code D0210) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not made aware of frequency 
limitations for the services. The Plan denied your request. The Plan says the benefits for both services have 
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 both requested items and services were exhausted on date of service September 23, 
2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (code 
D0150) and complete series of radiographic images (code D0210) provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 24, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 24, 2021 billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of dental implant on tooth #11 (D6100) provided 
on April 14, 2022. 
 
You asked the Plan to pay for the implant removal. You say that this service should be covered under your 
medical coverage. The Plan denied your request. The Plan says removal of a dental implant (D6100) is not 
covered by your supplemental dental benefit. 
 
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 
removal of dental implant on tooth #11 (D6100) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported removable denture (D6111) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the dental service. You say that these dentures should be covered at 50%. The 
Plan denied your request. The Plan says an implant supported removable denture (D6111) is not covered by 
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 implant 
supported removable denture (D6111) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and implant supported 
crown (D6066) provided on January 19, 2022. 
 
You asked the Plan to pay for the prefabricated abutment and implant supported crown. You say that you 
would like the Plan to cover these services because the provider will not change the coding. The Plan denied 
your request. The Plan says these 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 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 
prefabricated abutment (D6056) and implant supported crown (D6066) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) and an addition to an existing partial 
denture (D5650) provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an extraction (D7140) and addition to an existing partial denture 
(D5650) are not covered by 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 
extraction (D7140) and an addition to an existing partial denture (D5650) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed 
appropriately per the Medicare coding regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 25, 2021, billed with codes 81206 and 81292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 6, 2021, billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this claim has not been billed correctly per 
Medicare coding regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 6, 2021, billed with codes 81206 and 81292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 31, 2021, billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed correctly per 
Medicare coding regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 31, 2021, billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311.