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

 
We decided that the Plan does not have to waive the cost share for the office visit and ECG provided on May 
10, 2022. 
 
You asked the Plan to waive the cost share for the office visit and ECG. You say that the services should be 
covered because it was paid by insurance along with a physical previously. 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. Your 
contract with the Plan says that there is $800 deductible and for all other services, your coinsurance is 10% of 
the approved amount. The annual deductible applies. 
 
The item or service you asked the Plan to waive the deductible for falls within the diagnostic tests and doctor 
and other health care provider services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $800 deductible applies to the office visit and ECG. This cost sharing is a 
contractual obligation that had not been met at the time the office visit and ECG was received on May 10, 
2022. Therefore, $91.72 has been applied to meet the deductible. 
  Since the $800 deductible was met, you have also been asked to pay $10.19 for the office visit and ECG. The 
allowed amount is $251.88 (10% x $251.88 = $25.18), you were asked to pay $10.19, which is less than the 
$25.18 coinsurance. 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 the Plan does not have to waive the cost for the office visit and ECG provided on May 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 4, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the provider is an in-network provider, and the 
dental services should be covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the limited oral evaluation is not covered by 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 28, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on September 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care from August 20, 2022, to August 
21, 2022. 
 
You asked the Plan to pay for the SNF care. 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 hospice is not a plan 
covered benefit. 
 
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 skilled nursing facility care from August 20, 2022, to August 
21, 2022.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to provide coverage for Synvisc-One (Hylan G-F 20) for the enrollee.
You asked the Plan to provide coverage for Synvisc-One (Hylan G-F 20). You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says that the Plans step therapy rules were not met. Maximus upheld the Plans denial but named Prolia as the drug in question. Maximus discovered the error and reopened the case which required a second medical review.
Our Medical Director and our Senior Project Director looked at the case file. At issue is coverage for Synvisc-One (Hylan G-F 20). The enrollee has a diagnosis of osteoarthritis of the left knee with pain. Injections (2) are reported to be helping. Medical records are provided for the last Synvisc-One injection which was on April 2/, 2022. The enrollee also received Synvisc-One injections on May 19, 2020, and March 23, 2021. The Plan states that before Synvisc-One is covered, Euflexxa and one of the following (Durolane, Gelsyn-3 or Supartz FX) must be tried. It is noted by the provider's office that this enrollee has used Synvisc-One for over 4 years with great relief. Step therapy rules are to be applied only to new drug administrations, using at least a 365-day lookback period. The enrollee in this case has used Synvisc-One since at least 2020, with great relief reported. The rules say that health plans can only apply step therapy to new administration drugs using a 365-day lookback period. You can find this at 42 Code of Federal Regulations (CFR) 422.136. Since this last dose was in April of 2022, the 365 look back has not been exhausted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this request have been met. Therefore, we decided that the Plan has to provide coverage for Synvisc-One (Hylan G-F 20) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Sensor. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and intraoral x-
ray provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that these are legitimate and necessary procedures 
and should be covered. The Plan denied your request. The Plan says these services are not covered by the Plan's 
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 the 
problem focused limited oral evaluation and intraoral x-ray provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 3, 2022. 
 
You asked the Plan to pay for lab services.. You say that this should be paid for. 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 lab services provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cleaning 
(D1110) provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should still pay for the cleaning 
regardless of meeting the dental maximum. The Plan denied your request. The Plan says your dental benefit for 
the year 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 maximum dental benefit for the year was exhausted on the date of service of December 1, 2022. On 
May 19, 2022, the Plan paid $170.58 for dental services. On December 1, 2022, which was received and 
processed prior to this claim the Plan paid $829.42 for the dental services. For the year of 2022 the Plan paid 
$1,000 ($170.58 paid + $829.42 paid) for dental services. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150) and a cleaning (D1110) provided on November 30, 2022.  
 
Your complaint about coverage being allowed outside of the annual maximum coverage is not a valid appeal 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 7, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the service was for a different tooth, and it 
should be covered since it was not for the same tooth. 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 the date of service of April 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that you need the shower chair. The Plan denied your 
request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had 
the symptoms of a stroke and called 911. You also say that if you had known the fire department was coming 
you would have insisted on an ambulance service. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 11, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 16, 2022. 
 
You asked the Plan to pay for an office visit. You say that you hd spoken to the provider for new referrals. 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 November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive periodontal evaluation - new or 
established patient (D0180), bitewings - four radiographic images (D0274), and periodontal maintenance 
(D4910) provided on November 10, 2022. 
 
You asked the Plan to pay more for the comprehensive periodontal evaluation - new or established patient 
(D0180), bitewings - four radiographic images (D0274), and periodontal maintenance (D4910). You say that 
the mailing of the new card misrepresented the effective dates as the issue date. 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 for the  comprehensive periodontal evaluation - new or established patient (D0180), bitewings - four 
radiographic images (D0274). This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance (D4910) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more 
for a comprehensive periodontal evaluation - new or established patient (D0180), bitewings - four radiographic 
images (D0274), and periodontal maintenance (D4910) provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility provided on September 09, 2022. 
 
You asked the Plan to pay for subsequent nursing facility. You say that these services were medically 
necessary. 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 subsequent nursing 
facility provided on September 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve mental health services. You say that you feel that the in-network providers 
have not been able to treat your issues. Therefore, you want to go out-of-network to see someone who can. The 
Plan denied your request. The Plan says there is no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility. Therefore, the decision is upheld. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal maintenance, oral hygiene instructions, and the 
application of fluoride (D1330, D1206, D4910) provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your $1,250 dental benefit maximum allowance 
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 10, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodontal maintenance, oral hygiene instructions, and the 
application of fluoride (D1330, D1206, D4910) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (D9985) for dental services provided on 
September 19, 2022. 
 
You asked the Plan to pay for the sales tax. You say that you are appealing the denial. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 sales 
tax (D9985) for dental services provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (D3310), prefabricated 
post and core in addition to crown (D2954), pontic - porcelain fused to noble metal (D6242 x2), and retainer 
crown - porcelain/ceramic (D6740) provided on September 28, 2022. 
 
You asked the Plan to pay for endodontic therapy, anterior tooth (D3310), prefabricated post and core in 
addition to crown (D2954), pontic - porcelain fused to noble metal (D6242 x2), and retainer crown - 
porcelain/ceramic (D6740). You say that you were told by the Plan when you became active your dental would 
be paid. The Plan denied your request. The Plan says original Medicare doesn't cover preventative dental 
services.  
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 
endodontic therapy, anterior tooth (D3310), prefabricated post and core in addition to crown (D2954), pontic - 
porcelain fused to noble metal (D6242 x2), and retainer crown - porcelain/ceramic (D6740) provided on 
September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 29, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was an explanation of the 
surgery work and should be covered. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the consultation is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services represented by code (D1999) and provided on 
October 24, 2022. 
 
You asked the Plan to pay for the dental service D1999. The Plan denied your request. The Plan says this 
service is 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 pay for dental 
services represented by code (D1999) and provided on October 24, 2022.