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

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's dentures are loose, and they 
are not able to eat. 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 16, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and 
mandibular complete denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on September 22, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that there is no authorization or referral 
needed for this service. 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 new patient office visit 
provided on September 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services billed to the enrollee for May 4, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for no medical records. The Plan requested a reopen and provided documentation to show medical records were requested several times but were not received.

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. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan does not have to pay for medical services billed to the enrollee for May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for code 70450 billed for date of service December 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file regarding the billing of a previous claim. The Plan requested a reopen and provided the required documentation. The Plan noted that a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450-26 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the omission of the required modifier showing this was a separate and distinct service from those previously paid. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for code 70450 billed for date of service December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on February 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 February 22, 2023, when 
the Plan paid for two additional x-ray procedures. Therefore, we decided that the Plan does not have to pay for 
the bitewing x-rays (D0274) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewings, and fillings (D2392, 
D0272, D0120) provided on January 24, 2023 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation, bitewings, and fillings (D2392, D0272, D0120) provided on January 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were not made aware of the limitations. 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 October 8, 2019. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on November 
16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 13, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that these charges are 
absurd and should not be so high. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also clearly says you then pay a $0 copayment for any additional days of the same inpatient stay. 
 
You have been asked to pay a $360 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day five 
or for the day you were discharged. You have been asked to pay a total of $1,800 ($360 copayment per day x 5 
days = $1,800). 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 copayment for the inpatient hospital stay provided from 
November 13, 2022, to November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on July 6, 2022 and billed under code 83550.
You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information to show the overturned codes were previously paid.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 83550 is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met for code 83550 Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 83550.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary complete denture (D5110), mandibular 
complete denture (D5120) and panoramic x-ray (D0330) provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dentures accidentally got thrown away. 
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 June 21, 2021. Therefore, 
we decided that the Plan does not have to pay for the maxillary complete denture (D5110), mandibular 
complete denture (D5120) and panoramic x-ray (D0330) provided on November 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency room service provided on 
December 26, 2022. 
 
You asked the Plan to reduce the copayment for the emergency room service. You say that all services should 
be covered under the emergency room visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room service. This item/service falls within 
the emergency care 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. The record shows you are only being charged for the emergency room visit. Therefore, we decided 
that the Plan does not have to reduce the copayment for the emergency room service provided on December 26, 
2022.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services (76642) provided to the enrollee on August 22, 2022.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the MUE value for code 76642 changed from 2 to 1 on July 1, 2022. As of the date of service was August 2, 2022, the new MUE value would have applies.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, this claim could not be paid due to an error with MUE value for the code reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (76642) provided to the enrollee on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on November 
01, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that it is the responsibility of the 
facility to obtain authorization. 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 care visits provided on November 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, of a premolar tooth (excluding final 
restoration) (D3320) provided on August 16, 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 your benefit for the service provided 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 service provided was exhausted on October 18, 2022. Specifically, the Plan contract 
states that there is a $1,500 combined allowance for supplemental preventive and comprehensive dental 
services every year. The member is responsible for any amount over and above the allowance amount. The 
record shows that the Plan issued payment in the amount of $1,500 ($200 + $1,300) for the services provided 
on August 1, 2022 and October 14, 2022 accordingly. The claims for these services were received and 
processed before the claim for this service was submitted. Therefore, you have exhausted the allowable benefit 
for the service provided in this case. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy, of a premolar tooth (excluding final restoration) (D3320) provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 19, 2023, and January 
23, 2023, by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay for the services you 
received because you did not know the provider was out-of-network. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on January 19, 2023, and January 23, 2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
January 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for Emergency care. 
 
You have been asked to pay a $95 copayment for an emergency care visit. This item/service falls within the 
Emergency care 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 copayment for an emergency care 
visit provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each specialist office visit provided on 
October 20, 2022, to November 03, 2022. 
 
You asked the Plan to reduce the copayment for each specialist office visit. You say that you should have been 
charged only one $35 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. The total amount you owe is $105 ($35 copayment 
x 3 visits = $105). Therefore, we decided that the Plan does not have to reduce the copayment for each 
specialist office visit provided on October 20, 2022, to November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery, bone replacement graft, and biologic 
materials (D4265, D4261, D4263) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for osseous surgery, bone replacement graft, and biologic materials (D4265, D4261, D4263) provided on 
May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from June 12, 2022, to July 11, 2022.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that per the Medicare guidelines, the following data elements are required to submit a claim under home health PPS. For billing of home health claims not under an HH plan of care (not under HH PPS), see 90. Home health services under a plan of care are paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit one claim for each 30-day period of care. Claims submitted before an NOA has been received for the beneficiary will be returned to the provider.
A review of our systems shows that we never received a NOA from the provider for any series of care in 2022. According to the PPS claims submitted, the admission date for the HH series began on March 14, 2022. The plan never received a NOA from the provider for this series of home health care episodes. Per the above Medicare guidelines, the provider is required to send a NOA at the beginning of any admission to Home Healthcare. As the provider never sent an NOA, the Plan has correctly denied the PPS claim for payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to the absence of an appropriate NOA. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from June 12, 2022, to July 11, 2022.