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

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 31, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and explained that this claim was not billed the required unique identifier required by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim cannot be paid due to the omission of the required identifier. 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 October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and 
the retreatment of a previous root canal (D3348) provided from January 26, 2022, to February 21, 2022. 
 
You asked the Plan to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) 
and the retreatment of a previous root canal (D3348). You say that you are appealing the denied claim. The 
Plan denied your request. The Plan says the services are not covered 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 cone beam CT capture and 
interpretation (D0364) and the retreatment of a previous root canal (D3348) are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and 
interpretation (D0364) and the retreatment of a previous root canal (D3348) provided from January 26, 2022, to 
February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on April 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you checked this treating provider's 
participation status prior to signing up with this health plan, and would like these services to be covered. The 
Plan denied your request. The Plan says these dental services were received from an OON 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 OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) of the lower right quadrant or 
pay more for the periodontal scaling and root planing (D4341) of the lower right quadrant and provided on 
April 7, 2022. 
 
You asked the Plan to pay for the gingival irrigation of the lower right quadrant and to pay more for the scaling 
and planing of the lower right quadrant. You say that the Plan representative you spoke with advised that the 
claim would be paid by the Plan from the $1,500 dental allowance. The Plan denied your request. The Plan 
says your dental allowance for the 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 dental allowance for the requested service was exhausted after this claim was reprocessed on 
August 27, 2022, for the date of service April 7, 2022. Therefore, we decided that the Plan does not have to pay 
for the gingival irrigation (D4921) of the lower right quadrant or pay more for the periodontal scaling and root 
planing (D4341) of the lower right quadrant and provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dentures. 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 May 27, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820) provided May 10, 2022. 
 
You asked the Plan to pay for the upper interim partial denture. You say that you should not have to pay for a 
much-needed dental appliance. The Plan denied your request. The Plan says this service is not covered under 
your 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 the 
interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided 
May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two custom fabricated abutments (D6057 x2), and a mandibular implant/abutment 
supported removable denture for edentulous arch (D6111). 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments, and mandibular 
implant/abutment supported removable denture. The Plan denied your request. The Plan says these services are 
not covered under your benefit package. 
 
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 pre-approve two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two custom fabricated abutments 
(D6057 x2), and a mandibular implant/abutment supported removable denture for edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for teeth #18 and #19 provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you believe these should be covered. 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 will be exhausted on D2751 for teeth #2 and #3. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2751) for teeth #18 and #19 provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. 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 July 10, 2021, and July 
17, 2021. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing in all four quadrants (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam imaging (D0365). 
 
You asked the Plan to pre-approve imaging. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says cone beam imaging (D0365) 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 pre-approve cone 
beam imaging (D0365).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on December 27, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you were charged incorrectly. 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 $100
copayment for diagnostic procedures and tests at all locations of service. You have been asked to pay a $34.82
copayment for the x-ray. This procedure was not provided at an Independent Diagnostic Testing Facility, so a
$0 copayment is not indicated. This item/service falls within the diagnostic procedures and tests at all locations
of service benefit category. The provider billed less than your applicable copayment of $100 for the x-rays.
This means that you have been asked to pay less than 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 x-ray provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630), and bone replacement graft for ridge preservation - per site tooth #'s 2, 3, 18 (D7953). 
 
You asked the Plan to pre-approve drugs or medicaments dispensed in the office for home use (D9630), and 
bone replacement graft for ridge preservation - per site tooth #'s 2, 3, 18 (D7953). You say that you are asking 
to review and reconsider coverage. The Plan denied your request. The Plan says these services are not covered 
under the benefit package. 
 
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 pre-approve 
drugs or medicaments dispensed in the office for home use (D9630), and bone replacement graft for ridge 
preservation - per site tooth #'s 2, 3, 18 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial maxillary denture (D5820) and an 
interim partial mandibular denture (D5821). 
 
You asked the Plan to pre-approve interim dentures. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an interim partial maxillary denture (D5820) and an 
interim partial mandibular denture (D5821) are not covered by your routine 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 pre-approve an 
interim partial maxillary denture (D5820) and an interim partial mandibular denture (D5821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site 
(D4266x4), surgical placement of implant body: endosteal implant (D6010x4), custom fabricated abutment  
includes placement (D6057x4), implant /abutment supported fixed denture for edentulous arch  maxillary 
(D6114x4), bone replacement graft for ridge preservation - per site (D7953x4), and immediate denture - 
maxillary (D5130) provided on April 27, 2022. 
 
 You asked the Plan to pay for the dental services.. You say that you feel that your solution to choose dental 
implants was a much better solution than the denture approach offered in the Plan. You say that you would like 
the Plan to pay for the entire process. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 guided tissue 
regeneration - resorbable barrier, per site (D4266x4), surgical placement of implant body: endosteal implant 
(D6010x4), custom fabricated abutment  includes placement (D6057x4), implant /abutment supported fixed 
denture for edentulous arch  maxillary (D6114x4), bone replacement graft for ridge preservation - per site 
(D7953x4), are not among those covered under this benefit. The record shows your benefit for the immediate 
denture  maxillary (D5130) was exhausted on date of service March 8, 2022. 
 
Therefore, we decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per 
site (D4266x4), surgical placement of implant body: endosteal implant (D6010x4), custom fabricated abutment 
 includes placement (D6057x4), implant /abutment supported fixed denture for edentulous arch  maxillary 
(D6114x4), bone replacement graft for ridge preservation - per site (D7953x4), and immediate denture - 
maxillary (D5130) provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 31, 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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Medicare requires all claims billed for Molecular Diagnostic Tests to be billed with a unique test identifier. Per L35025, is applicable as per Box (32) for electronic, Box 11 if 32 is empty, if paper Box 32 (only) shows the lab was rendered. This LCD clearly shows that all tests billed within this jurisdiction are required to be billed with a Unique Test Identifier. There is no Unique Test Identifier issued by MolDX billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim cannot be paid due to the omission of the required identifier. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on November 16, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this vision benefit was previously exhausted. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that the claim history shows the Plan made a payment in the amount of $95.60 for eyewear purchased on June 16, 2020, exhausting the benefit. As per the contract, this benefit is allowed every two years and would have been available again on June 16, 2022.
The Plan is correct in this case. 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 this service ever two years. The records show this benefit was not yet available on the date of service. Therefore, we decided that the Plan does not have to pay for vision services provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), panoramic x-ray (D0330), four two dimensional (2D) oral/facial photographic 
images (D0350 x4), and mandibular partial denture (D5226) provided from April 14, 2022, to April 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dental office over the 
phone that you were approved for partials, and your insurance would cover them. 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. The Plan also says that neither you, nor the provider, contacted the health plan 
prior to services being rendered to confirm the provider's eligibility or your 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. The record shows that there are contracted 
providers available within the time and distance standards set forth by Medicare to provide the services at 
appeal. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), complete series of intraoral x-rays (D0210), panoramic x-ray (D0330), four two dimensional (2D) 
oral/facial photographic images (D0350 x4), and mandibular partial denture (D5226) provided from April 14, 
2022, to April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polarized lens coatings (V2762) and the high-index lens 
(V2783) provided on June 7, 2022. 
 
You asked the Plan to pay for the polarized lens coatings and the high-index lens. You say that the provider 
advised you get these lenses because you have blue eyes and underwent cataract surgery. The Plan denied your 
request. The Plan says you were not eligible for these custom lens options. 
 
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 standard CR29 single, bifocal, trifocal, and standard progressive lenses in full. 
 
 
 We looked at the file and the Plan's rules. The record shows that you received lens enhancements, which are 
not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the 
polarized lens coatings and the high-index lens have not been met. Therefore, we decided that the Plan does not 
have to pay for the polarized lens coatings (V2762) and the high-index lens (V2783) provided on June 7, 2022.