Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventative visit and the specimen transfer provided on 
November 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the preventative visit and the specimen transfer. You say that you think that these 
services should be covered. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the preventative visit and the specimen transfer 
provided on November 23, 2022, by an out-of-network (OON) provider.  
 
Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Kansas City CMS Regional Office so that it can look into your enrollment question.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, (D7210), and placement of intra-socket biological dressing to aid in hemostasis or clot 
stabilization, per site (D7922) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D7210 and D7922. You say that you 
believe that 50% of your responsibility of $235 should be paid. 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 pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, (D7210), and placement of 
intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) provided on May 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view - less than one whole jaw (D0364) and removal of benign odontogenic cyst or tumor - lesion diameter 
up to 1.25 cm (D7450) provided on October 25, 2022. 
 
You asked the Plan to pay for dental services. You say that the services were needed due to an infection, also, 
you say that you do not have a good understanding of our policy. The Plan denied your request. The Plan says 
these services are not covered under your 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. Cone beam CT capture and 
interpretation with limited field of view - less than one whole jaw (D0364) and removal of benign odontogenic 
cyst or tumor - lesion diameter up to 1.25 cm (D7450) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0364 and D7450 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364) and removal 
of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140) and the resin-based 
composite (D2140) for tooth #28 provided on October 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you did not get a cleaning and the tooth 
was exposed and would not look good on a front facing tooth. The Plan denied your request. The Plan says 
your benefit for the limited oral evaluation has already been exhausted. Also, you are responsible for the 
coinsurance and the difference in allowed amount for the resin-based composite. 
 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 limited oral evaluation was exhausted on the date of service of June 10, 2022. The 
total amount billed for the resin-based composite was $121.13 and the total allowed amount was $95.98 
leaving a difference of $25.15 ($1121.13 billed - $95.98 allowed). The total coinsurance amount was $47.99 
($95.98 allowed x 50% coinsurance). The total for the difference and coinsurance amount was $73.14. 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 the limited oral evaluation (D0140) and the resin-based composite 
(D2140) for tooth #28 provided on October 5, 2022.
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 October 25, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
medical records provided support the need for the ambulance transport. 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 October 25, 2021. 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 October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 28, 2022, billed 
with code 70544. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis was invalid as reported. 
 The Plan must follow Medicare rules. Medicare rules say that the reason for the encounter should be billed as 
the primary diagnosis code and the appropriate family history code should be assigned as additional diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of imaging services provided have not been met. The claim was billed with Z82.49 as the principal 
diagnosis, which is a family history code. Therefore, we decided that the Plan does not have to pay for imaging 
services provided on December 28, 2022, billed with code 70544.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided 
on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that this 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 was exhausted on date of service September 8, 2022. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) 
provided on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on October 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on October 
21, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130) provided on 
December 13, 2022. 
 
You asked the Plan to pay for the immediate denture - maxillary. You say that you always see this dentist and 
you are not sure why this visit was denied. 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 an 
immediate denture - maxillary (D5130) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation-new/established patient 
(D0150) provided on November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this 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 was exhausted on date of service September 29, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation-new/established 
patient (D0150) provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) provided on 
December 30, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown procedure. You say that you received a bill and a 
harassment call from the provider. You also say that this bill should be paid by your insurance. 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 a re-
cement or re-bond crown (D2920) provided on December 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on December 30, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
We looked at the file and Medicare rules. The record shows that the enrollee had the injection (64483) 
performed on December 30, 2022. The MFSDB shows that the postoperative period for this code is the day of 
surgery/procedure. The enrollee received the Bupivacaine (J3490) injection on December 30, 2022, which is 
the same day the initial procedure was rendered. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 provided on December 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
radiographic images (D0210), and the cleaning (D1110) provided on October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never received an update that you reached 
your maximum allowed for the year. The Plan denied your request. The Plan says your maximum 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 the Plan paid $156 for dental services on April 11, 2022. On May 2, 2022, the Plan paid $1,194 for 
dental services. For the year of 2022 the Plan paid $1,350 ($156 paid + $1,194 paid) for dental services; 
therefore, your maximum dental benefit for the year of 2022 was exhausted on the date of service of May 2, 
2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
the intraoral radiographic images (D0210), and the cleaning (D1110) provided on October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eCoin neuromodulation device. 
 
You asked the Plan to pre-approve an eCoin neuromodulation device. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 eCoin neuromodulation device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a review of the current medical literature indicates that eCoin is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. There is a lack of well controlled studies demonstrating long term safety and effectiveness of eCoin. The studies evaluating this device have had 
small sample sizes and lack controls and randomization of subjects. The eCoin neuromodulation device is not 
medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an eCoin neuromodulation device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an eCoin neuromodulation device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction 
device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 insertion of an interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found interspinous devices are 
experimental. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics provided on November 30, 2022. 
 
You asked the Plan to pay for orthotics. You say that you are requesting reconsideration. 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 orthotics provided on 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment services provided 
on April 26, 2022, by an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for remote physiologic monitoring treatment services. You say that you are 
requesting reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care 
from a network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for remote physiologic monitoring treatment services 
provided on April 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 billed for date of service August 29, 
2022. 
 You asked the Plan to pay for procedure code 29581. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 29581 is bundled into 
payment for code 11042. 
 
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 29581 
is a column II code to column I code 11042. 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 29581 billed for date of service August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy x-ray absorptiometry (DXA) scan provided on 
July 19, 2021. 
 
You asked the Plan to pay for a dual-energy x-ray absorptiometry (DXA) scan. You say that this was medically 
necessary and should be covered. 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 a dual-energy x-ray 
absorptiometry (DXA) scan provided on July 19, 2021.