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

 
We decided that the Plan does not have to pre-approve implant placement for tooth #5 and a bridge from tooth 
#29-31. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a bridge can be approved when there is only one missing upper front tooth, or two lower 
front teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the plan limitations 
say "Restorations (including crowns, bridges, inlays, and onlays) when acceptable results can be achieved with 
less costly methods or materials. [The Plan} will cover the least costly treatment option." In this instance the 
missing tooth #30, as well as the posterior teeth on the opposite side of the arch, could be restored with a 
removable appliance, which would be the least costly option. Under the Plan provisions, therefore coverage 
would not be allowed for a posterior bridge. Under the Plan limitations, there is a specific exclusion for "Dental implants and all associated services."  The request for implant services for tooth #5 therefore are excluded from 
coverage and does not meet criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implant placement for tooth #5 and a bridge from tooth #29-31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided September 29, 2021. 
 
You asked the Plan to pay for the dental cleaning. You say that you would like this cleaning covered. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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. The Plan covers the dental 
cleaning twice per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dental cleanings were 
previously covered on January 19, 2021, and May 25, 2021. Based on this information, we decided that the 
Plan's frequency limit for coverage of the dental cleaning has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis - adult (D1110) provided September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140 x 2) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist was not able to perform the 
services. You say that the dentist in this case has provided services that are necessary. You also say that you 
were advised by your plan that the services were covered. The Plan denied your request. The Plan says 
extractions are not a covered service. The Plan also says that you were not given misinformation. 
 
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 extractions are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7140 
x 2) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a denture. You say that this denture is necessary. The Plan denied your 
request. The Plan says this item is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393), bitewing radiographic 
images (D0274), and cleaning (D1110), provided on November 1, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you received these services from a provider who has opted out of Medicare. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
resin-based composite (D2393), bitewing radiographic images (D0274), and cleaning (D1110), provided on 
November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implants (D6010), removal of lateral exostosis 
(D7471), and cone beam CT capture (D0367) provided by a participating provider on February 5, 2021. 
 
You asked the Plan to pay for endosteal implants, removal of lateral exostosis, and cone beam CT capture. You 
say that these services are medically necessary. The Plan denied your request. The Plan says these services 
have been correctly denied. 
 
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 endosteal implants (D6010), removal of lateral exostosis (D7471), and cone beam CT capture (D0367) provided by a 
participating provider on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) 
provided by an out-of-network provider on January 19, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you have had this dentist 
for a long time. You say that it is not fair that the Plan changed their policy on out-of-network provider. The 
Plan denied your request. The Plan says this claim has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a periodic 
oral evaluation and prophylaxis when the services are provided in-network.  
 
We looked at the file and Medicare rules. Services that are provided out-of-network are not covered by the 
Plan. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation (D0120), and prophylaxis (D1110) provided by an out-of-network provider on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical application of fluoride varnish (D1206). 
 
You asked the Plan to pre-approve fluoride varnish. You say that this service is medically necessary. The Plan 
denied your request. The Plan says you will exceed the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers fluoride 
varnish once per year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a fluoride treatment 
was previously covered on March 31, 2022. Based on this information, we decided that the Plan's frequency 
limit for coverage of fluoride varnish will be exceeded with the requested service. Therefore, we decided that 
the Plan does not have to pre-approve topical application of fluoride varnish (D1206).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies provided to the enrollee
on July 20, 2021.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim overlaps payment to another provider for this type of supplies provided to the
enrollee. Maximus overturned the Plans denial because the case file did not contain the claim paid to the other
provider. The Plan requested a reopen and provided a copy of the paid claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, we show the
Plan paid another provider or these supplies for this date of service. Medicare rules for coverage of these
supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose
monitor supplies provided to the enrollee on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical placements of implant bodies: endosteal 
implants (D6010 x3), three custom fabricated abutments (D6057 x3), and three abutment supported porcelain 
fused to metal crowns (D6059 x3). 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments, and abutment 
supported porcelain fused to metal crowns. You say that you would like to appeal these services. The Plan 
denied your request. The Plan says these services are not covered under your benefit 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three 
surgical placements of implant bodies: endosteal implants (D6010 x3), three custom fabricated abutments 
(D6057 x3), and three abutment supported porcelain fused to metal crowns (D6059 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON pain management services. You say that your previous pain 
management provider stopped accepting your plan. You say that the enrollee has neuropathy in his feet and low 
back pain. You say that the requested provider is close to the enrollee's house. The Plan denied your request. 
The Plan says there is no medical need shown as to why the enrollee cannot get this care from a provider within 
the network. 
 Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. 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 were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from the enrollee's home who can provide 
pain management services. We found no exception that would require the Plan to pre-approve OON pain 
management services. Therefore, we decided that the Plan does not have to pre-approve pain management 
services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the requested feature is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation feature is non-covered. Based on 
this information, we decided that Medicare rules for coverage of the power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair purchased on October 30, 2021. 
 
You asked the Plan to pay for these services. You say that you would like to be reimbursed. The Plan denied 
your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were purchased from a 
provider not certified in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
lightweight wheelchair purchased on October 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and extraction (D7210), 
provided on October 24, 2021, to October 28, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you obtained these services through a provider who has opted out of 
Medicare. 
 
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 
limited oral evaluation (D0140), and extraction (D7210), provided on October 24, 2021, to October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gum surgery (D4211 x 2), and desensitizing resin (D9911 
x 4) provided on December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were in fact necessary. You say that 
the provider does not do silver fillings because mercury is unsafe. You also say that the services should be 
covered. The Plan denied your request. The Plan says the gum surgery is included in another treatment you 
had. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the gum surgery. Our reviewer says that the 
gum surgery was not medically necessary. Our physician reviewer found that the radiographs submitted did not 
show that gum surgery was required to gain access to the caries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental have not been met. Specifically, the file does not show that gum surgery 
was necessary to gain access to the caries. Additionally, desensitizing resin is not a covered service. Therefore, 
we decided that the Plan does not have to pay for the gum surgery (D4211 x 2), and desensitizing resin (D9911 
x 4) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the consultation (D9310), inhalation of nitrous 
oxide (D9230), extraction (D7140), and removal of impacted tooth (D7241) provided on December 6, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you had to reschedule an emergency 
wisdom tooth extraction. You also say that you need at least part of this claim to be covered. The Plan denied 
your request. The Plan says the maximum benefit has 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, the maximum benefit of $775 has been 
exhausted. The record shows that the Plan paid $315 for services received on June 14, 2021, $238 for services received on November 3, 2021, $115 for services received on November 19, 2021, and $107 for services 
received on December 6, 2021. $315 + $238 + $115 + $107 = $775. Therefore, we decided that the Plan does 
not have to reimburse you for the consultation (D9310), inhalation of nitrous oxide (D9230), extraction 
(D7140), and removal of impacted tooth (D7241) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for this equipment.
You asked the Plan to provide coverage for this equipment. You say that these items are medically necessary
for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial for a lack of medical records. The Plan requested a reopen and submitted the
required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a prosthetic leg
with an advanced foot feature, rotational unit, a vertical load pylon, and other additions. The medical records
how the enrollee was a then 47-year-old woman who underwent a below-knee amputation of her right leg.
The re-opening request contains a Progress Note dated October 12, 2021. Phantom limb pain is documented.
The clinical documentation provided does not sufficiently support that the coverage criteria for a prosthetic leg
with an advanced foot feature, rotational unit, a vertical load pylon, and other additions, were met 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 the requested equipment have not been met. Therefore, we decided that the Plan
does not have to provide coverage for a prosthetic leg with an advanced foot feature, rotational unit, a vertical
load pylon, and other additions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that you need this implant and feel it is 
medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefit 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospice related services provided to the enrollee from April
18, 2020, to April 19, 2020.
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 the claim records show the enrollee was not under hospice election for these dates of
service, therefore, the claim is not coded correctly. Maximus overturned the Plans denial for a lack of claim
history information in the file. The Plan requested a reopen and provided the enrollee's status history.
The Plan is correct in this case. 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. However, in this
case, the enrollees claim history shows the enrollee was not under hospice election on the dates of service
billed. Therefore, the claim cannot be paid as it was billing incorrectly. Therefore, we decided that the Plan
does not have to pay for hospice related services provided to the enrollee from April 18, 2020, to April 19, 2020.