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

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at the L4-5 level, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery provided on August 27, 2021, that was
applied to the 2021 deductible.
You asked the Plan to pay for this service. You say that you do not believe the bill for this service is correct.
The Plan denied your request. The Plan says the cost of this service was applied to your yearly deductible.
Maximus overturned the Plans denial. The Plan stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan says that there was $750 deductible which applied to
2021. The service provided fell within the 2021 benefit category that required the deductible. Both the original
case file and the reopen request from the Plan contained the information needed to confirm that at the time of
service, your $750 deductible had not been satisfied. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is $750 deductible which applied to 2021. The deductible is a contractual
obligation that had not been met at the time this service was received on August 27, 2021. Therefore, we
decided that the Plan does not have to pay for outpatient surgery provided on August 27, 2021, that was applied
to the 2021 deductible.
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  and, including elevation of mucoperiosteal flap if indicated(D7210) provided on November 
21, 2022. 
 
You asked the Plan to pay for the extraction. You say that all they gave you was a shot of Novocain and pulled 
your tooth, so what makes this surgical. 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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth  and, including elevation of 
mucoperiosteal flap if indicated(D7210) provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified oral surgery (D7999) for tooth #4 provided 
on October 12, 2022. 
 
You asked the Plan to pay for the dental service. You say that your insurance card says dental services are 
covered and you do not understand why it does not cover your dental needs. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the unspecified oral surgery 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 the 
unspecified oral surgery (D7999) for tooth #4 provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services provided to the enrollee and billed under code 87150.
You asked the Plan to pay for this code. The Plan denied your request. The Plan says while a portion of this
claim was paid, the medical records provided do not include the results for code 87150. Maximus overturned
the Plans denial stating the records show this type of testing was medically necessary. The Plan requested a
reopen and stated the argument was not that the services were not necessary but that the lack of results of the
testing question if the service was performed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider,
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to
determine whether payment is due and the amount of payment.
Based on the records provided, the documentation is not complete and there is insufficient information in the
record to determine if Medicare rules for coverage of code 87150 were met. Therefore, we decided that the
Plan does not have to pay for lab services provided to the enrollee and billed under code 87150.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure, by report 
(D5899) provided on April 15, 2022. 
 
You asked the Plan to pay for code D5899. You say that you are asking for a review and to reconsider 
payment. 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 unspecified removable 
prosthodontic procedure, by report (D5899) is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure, by report 
(D5899) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the crown - porcelain/ceramic tooth #'s 30 
and 31 (D2740) provided on August 31, 2022. 
 
You asked the Plan to waive the coinsurance for the crowns. You say that due to COVID-19 and other reasons 
your dentist was not able to perform the dental work. You also say that you were in pain so you chose an out-
of-network provider. 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 50% 
coinsurance for crowns.  
 
You have been asked to pay 50% coinsurance for the crowns. This service falls within the major dental services 
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 waive the coinsurance for the crown - porcelain/ceramic 
tooth #'s 30 and 31 (D2740) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of a tooth (D7210) for tooth #28 
provided by an out-of-network provider on October 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was an emergency and you 
thought it would be covered. The Plan denied your request. The Plan says the dental service was received from 
an out-of-network provider and is 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 service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for the surgical removal of a tooth (D7210) for tooth #28 provided by an out-of-network provider on 
October 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluticasone-Vilanterol. 
 
You asked the Plan to pre-approve Fluticasone-Vilanterol. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fluticasone-Vilanterol.  
 
Benefits for Fluticasone-Vilanterol may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) and intraorifice 
barrier (D3911) provided on September 13, 2022. 
 
You asked the Plan to pay for dental services. You say that your provider did not inform you that these 
procedures were not covered under your insurance. 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. Treatment of root canal 
obstruction (D3331) and intraorifice barrier (D3911) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D3331 and D3911are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for treatment 
of root canal obstruction (D3331) and intraorifice barrier (D3911) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0367) provided on September 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that you called the Plan, and they told you the 
provider was in-network and the service provided was necessary. The Plan denied your request. The Plan says 
the denial of payment for this service is correct because the cone beam is not covered by the Plan. Also, it was 
verified that the enrollee was given 3 in-network providers along with a copy of their complete dental benefits 
and the rendering provider was not 1 of them. 
 
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 cone 
beam (D0367) provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve therapeutic CGM and supplies. You say that the enrollee will benefit from 
using a therapeutic CGM. 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 
therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve therapeutic CGM and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic 
images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic 
image (D0220) provided on November 16, 2022. 
 
You asked the Plan to pay for codes D1110, D0274, D0120, and D0220. You say that you were promised that 
the additional dental coverage would be added on October 1, 2022. The Plan denied your request. The Plan 
says you do not have non-Medicare covered dental benefits with the Plan since you did not elect coverage in 
the optional supplemental dental benefit. 
 
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 prophylaxis - adult (D1110), 
bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral 
- periapical first radiographic image (D0220) provided on November 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on March 25,
2022, and billed under codes 99204 and 72040.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says these services were not billed correctly. Maximus partially overturned the
Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity
but the fact that the claim was not billed correctly. The Plan claim denied because this service was billed with
an inappropriate place of treatment or place of service code. The records show these services were provided at
a nursing home via mobile or portable x-ray.
which are denied as an excluded place of service. The documentation does not support the studies as billed
with a Place of Service code of 11 or an in-office service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Medicare rules say that when services are provided by a mobile unit, the mobile unit
should bill the POS as the entity that is being served. Under Medicare rules, POS 31 or Skilled Nursing
Facility should have been billed as that is where the service took place. POS 11 for in-office was billed in error.
Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on
March 25, 2022, and billed under codes 99204 and 72040.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230) and the periodontal 
scaling and root planning (D4341) provided on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that there was no dental work done and you needed 
a cleaning. The Plan denied your request. The Plan says your benefit for the intraoral radiographic image has 
already been exhausted. The periodontal scaling and root planning 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, certain limitations apply. On October 
18, 2022, the Plan paid for an intraoral radiographic image (D0220); therefore, your benefit for the introral 
radiographic image was exhausted on the date of service of October 18, 2022. The periodontal scaling and root 
planning is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for the intraoral radiographic image (D0230) and the periodontal scaling and root planning (D4341) 
provided on October 18, 2022.  Your complaint about the charges being too high 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 periodontal maintenance (D4910) provided on November 1, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance (D4910). You say that this was a regular cleaning 
and should be coded that way. 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 
periodontal maintenance (D4910) provided on November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 copayment charged for a diagnostic vision exam
provided to the enrollee on February 23, 2022.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial for a lack of medical records in the file. The Plan requested a reopen and provided the required records.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $35 copayment for
diagnostic vision exams. The medical records submitted show your physician billed this as a diagnostic vision
exam. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the $35 copayment charged for a diagnostic vision
exam to the enrollee on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and doctor services provided on November 23, 
2022. 
 
You asked the Plan to pay for an office visit and doctor services. You say that you feel these services should be 
covered because you were treated for an infection, and not dental. 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. Office visit and doctor 
services are not covered under the Plans dental benefits. 
 
  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 office 
visit and doctor services provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implants and associated services provided on January 
24, 2022, to August 31, 2022. 
 
You asked the Plan to pay for dental implants and associated services. You say that your grandson kicked you 
in the mouth. You say that you needed these implants. The Plan denied your request. The Plan says the 
rendered dental 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 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 
implants and associated services provided on January 24, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) and the x-ray exam of the entire 
thoracic and lumbar spine (72083) provided on October 19, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99205) and the x-ray exam of the entire thoracic and 
lumbar spine (72083) provided on October 19, 2022.