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

 
We decided that the Plan does not have to pay for the dental scaling (D4346) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that codes D4341 and D4342 are covered, so this 
code (D4346) should be too. The Plan denied your request. The Plan says the dental scaling (D4346) is not 
covered under your supplemental 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 dental 
scaling (D4346) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral x-rays (D0210), 
and prophylaxis (D1110) provided on January 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not find out until February that you 
were signed up with no dental coverage. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), intraoral x-rays (D0210), and prophylaxis (D1110) provided on January 13, 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 New York CMS Regional Office so that it can look into your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11102 billed for date of service December 
27, 2021. 
  You asked the Plan to pay for procedure code 11102. The Plan denied your request. The Plan says payment for 
code 11102 is bundled into payment for code 17110. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11102 
is a column II code to column I code 17110. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11102 billed for date of service December 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services provided on March 21, 2022. 
 
You asked the Plan to pay for the routine vision services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says there is a $150 allowance toward the cost 
of routine contact lenses or eyewear every year. This benefit is administered on a rolling calendar year since 
your last date of service. In this case, your last date of service for eyeglasses was April 3, 2021, and you were 
not eligible for new eyeglasses until April 3, 2022. Furthermore, the visual field examination you received was 
appropriately denied as the provider was a non-participating vision care provider under the routine vision 
services supplemental benefit. 
 
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.  
 
We looked at the file and the Plan's rules. In this case, there is a $150 allowance toward the cost of routine 
contact lenses or eyewear every year. This benefit is administered on a rolling calendar year since your last date 
of service. In this case, your last date of service for eyeglasses was April 3, 2021, and you were not eligible for 
new eyeglasses until April 3, 2022. Furthermore, the visual field examination you received was appropriately 
denied as the provider was a non-participating vision care provider under the routine vision services 
supplemental benefit. Based on this information, we decided that the Plan's rules for coverage of the routine 
vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
vision services provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 billed for date of service 
September 17, 2021. 
 You asked the Plan to pay for procedure codes 87150 and 87641. You say that these services were necessary 
and reported appropriately. The Plan denied your request. The Plan says payment for codes 87150 and 87641 is 
bundled into payment for codes 87500 and 87150, respectively. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87641 
is a column II code to column I code 87150, and code 87150 is a column II code to column I code 87500. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150 and 87641 billed for date of service September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on February 11, 
2022. 
 
You asked the Plan to pay for moderate sedation services (99153) provided on February 11, 2022. You say that 
the claim should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says 
procedure codes 50432 and 99152 are being overturned. The Plan also says payment for procedure code 99153 
is included in payment to the facility and not separately reimbursable to the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99153 have not been met. 
Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on 
February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the eye exam provided on March 23, 2022. 
 
You asked the Plan to fully pay for the eye exam. You say that you are not sure why you were charged $135. 
The Plan denied your request. The Plan says the claim reprocessed to pay for the $100 service that originally 
denied. The Plan also says the $35 copayment applied 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 $35 
copayment for each Medicare-covered eye exam.  
 
 
  You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the Vision 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 fully pay for the eye exam provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84479 and 84480 billed for date of service 
November 23, 2021. 
 
You asked the Plan to pay for codes 84479 and 84480. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says the payment for codes 84479 and 84480 is 
bundled into the payment for other services billed on the same claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 84479 
is a column II code to column I code 84439, and 84480 is a column II code to column I code 84481. Both code pairs have a modifier indicator of 0. The column II codes are therefore not payable. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 84479 and 84480 billed for date of service November 23, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service November 12, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 82435, 84132, and 84295 is 
bundled into payment for code 80051. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
82435, 84132, and 84295 are column II codes to column I code 80051. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 
billed for date of service November 12, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (G0483) provided on February 21, 2022. 
 
You asked the Plan to pay for drug testing. You say that you are being forced to pay for services for which you 
should not be responsible. The Plan denied your request. The Plan says that they have agreed to pay for your 
office visits, less your copayments; however, the drug testing was not coded correctly and is denied as the 
medical records do not support the testing of 22 or more classes of drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0483 requires that 22 or more classes of drugs are tested. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the  medical records show that 
at least 22 classes of drugs were tested in this panel, including: alkaloids (not otherwise specified), 
amphetamines, benzodiazepines, buprenorphine, cannabinoids (natural), cocaine, fentanyls, gabapentin (non-
blood), heroin metabolite, methadone, methylenedioxyamphetamines, methylphenidate, opiates, opioids and 
opiate analogs, oxycodone, phencyclidine, pregabalin, sedative hypnotics (non-benzodiazepines), skeletal 
muscle relaxants, stimulants (synthetic), tapentadol and tramadol. Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
the drug testing services (G0483) provided on February 21, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #8 and 9 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that this service should be covered. The Plan denied your 
request. The Plan says that there is no evidence of decay or missing crowns to support the need for 
replacements. 
 
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 crowns when 
the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that a review of the documentation does not 
indicate recurrent caries. Crown replacement for esthetic reasons is not a covered benefit. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a crown on tooth #8 and 9 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can control the power options with their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is 
medically necessary for any of the functions listed in the rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller. Our reviewer 
says that the requested expandable controller is not medically necessary. Our physician reviewer found you do 
not need to control the power options through a joystick. Your upper extremity strength supports that you can 
control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation on the left at L4-L5 and L5-S1.
You asked the Plan to pre-approve radiofrequency ablation. You say that radiofrequency ablation is medically
necessary. The Plan denied your request. The Plan says radiofrequency ablation does not meet the Medicare
coverage criteria.
The Plan follows Medicare rules.
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 radiofrequency ablation. Our reviewer
says that radiofrequency ablation on the left at L4-L5 and L5-S1 is not medically necessary. Our physician
reviewer found that you have a diagnosis of spondylosis without myelopathy or radiculopathy, lumbar region.
You had one prior lumbar medial branch block with 10-20% pain relief in 7 days. The case file does not
contain documentation that you had at least two medically reasonable and necessary diagnostic MBBs, with
each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of
relief being consistent with the agent used).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation on the left at L4-L5 and L5-S1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #6 (D2740), crowns on tooth #7, 8, 9, 10, 
and 11 (D2710), and resin-based composite fillings on tooth #22, 23, 24, 25, 26, and 27 (D2335) provided on 
February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says that crowns (D2740, D2710) are not covered by the dental benefits. The 
Plan also says that replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction 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 Plans coverage rules apply in this case. The Plan covers fillings when 
the services are medically necessary and reasonable.  
 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 the fillings. Our physician reviewer found 
that in this case it appears that the loss of coronal structure is due to abrasion, erosion, attrition or abfraction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fillings have not been met. Though the Plan offers a dental benefit in excess 
of Medicare coverage, the crowns are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for a crown on tooth #6 (D2740), crowns on tooth #7, 8, 9, 10, and 11 (D2710), 
and resin-based composite fillings on tooth #22, 23, 24, 25, 26, and 27 (D2335) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can control the power options with their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is 
medically necessary for any of the functions listed in the rules section.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller. Our reviewer 
says that the requested expandable controller is not medically necessary. Our physician reviewer found the 
records indicate that the enrollee has the upper extremity strength and function to operate the wheelchairs 
power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on March 31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that the dentist was no 
longer a participating provider. 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. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a bone replacement 
graft (D4263) provided on December 15, 2021. 
 
You asked the Plan to pay for an evaluation and a replacement graft. You say that you were wrongfully 
charged. The Plan denied your request. The Plan says a limited oral evaluation (D0140) and a bone 
replacement graft (D4263) 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. 
 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) and a bone replacement graft (D4263) provided on December 15, 2021.