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

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 7, 
2022. 
 You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99223 is bundled into payment for code 61645. 
 
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 99223 
is a column II code to column I code 61645. 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 99223 billed for date of service December 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5226) provided on June 1, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by Aspen Dental that you would 
not have to pay for this. 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 August 11, 2020. Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5226) provided on 
June 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical supply and PET scan provided on 
November 7, 2022. 
 
You asked the Plan to waive the copayment for medical supply and PET scan. You say that these services were 
required by you provider as part of your cancer treatment. 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 20% 
coinsurance for each Medicare-covered medical supply and $120 copayment for Medicare-covered radiological 
diagnostic services, not including X-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic). You pay these amounts until you reach the out-of-pocket maximum. 
 
You have been asked to pay a total of $$1,184.55 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
November 7, 2022 Medical supply $5,322.73 20% $1,064.55 
November 7, 2022 PET scan $1,397.38 $120 $120 
TOTAL:    $1,184.55 
 
The medical supply and PET scan falls within the outpatient diagnostic tests and therapeutic services and 
supplies 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 medical supply and PET 
scan provided on November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided on June 27, 2022.
You asked the Plan to pay for these services. You say that you believe the Plan should pay for these services.
The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the
Plans denial for insufficient information in the file to confirm the deductible was not met. The Plan requested a
reopen and provided the required information.
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 2022 contract shows there was a $750 deductible which applied to surgery
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750
deductible. This cost sharing is a contractual obligation that had not been met at the time these services were
received. Therefore, we decided that the Plan does not have to pay for surgery services provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for a telehealth visit provided on
September 2, 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 you had a telehealth visit with a dermatology specialist which requires
a $30 copayment, Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not apply the correct contract 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $30 copayment for telehealth specialist visits. A dermatologist is a specialist.
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 charged for a telehealth visit provided on
September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99205 billed for date of service December 1, 
2022.  
 
You asked the Plan to pay for procedure code 99205. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99205 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99205 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99205 billed for date of service December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on February 13, 2023. 
 
You asked the Plan to pay for anesthesia services. 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 anesthesia services 
provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service November 
29, 2022. 
 You asked the Plan to pay for procedure code 99213. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 20611. 
 
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 99213 
is a column II code to column I code 20611. 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 99213 billed for date of service November 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on January 24, 2023, 
by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 endodontic therapy (D3330) provided on January 24, 2023, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for PT services provided from June 10, 2022, to 
March 9, 2023. 
 
You asked the Plan to waive the cost share for PT services. You say that you are requesting the Plan to apply 
an in-network cost share and to reimburse your out-of-pocket expenses. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to PT services and 30% coinsurance 
for each out-of-network Medicare-covered physical and speech therapy service, after the $1,000 plan 
deductible.  
 You are asked to pay a total cost share of $2,549.24 for PT services. This total includes the 2022 and 2023 
yearly plan deductibles and 30% coinsurance for each PT service, after the deductibles were met. The item or 
service you asked the Plan to waive the cost share for falls within the outpatient rehabilitation services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to PT services. This cost sharing is a contractual obligation that had not been met at 
the time PT services was received on June 10, 2022, to March 9, 2023. Therefore, we decided that the Plan 
does not have to waive the cost share for PT services provided from June 10, 2022, to March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic images (D0350) and oral hygiene 
instructions (D1330) provided on February 22, 2023. 
 
You asked the Plan to pay for oral/facial photographic images and oral hygiene instructions. You say that this 
should be covered. The Plan denied your request. The Plan says this is not a covered 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. 
 
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 oral/facial 
photographic images (D0350) and oral hygiene instructions (D1330) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, adjust partial 
dentures, and occlusal adjustment (D5422, D0140, D9951, D0220) provided on January 9, 2023, to January 17, 
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 limited oral evaluation, intraoral x-ray, adjust partial dentures, and occlusal adjustment (D5422, 
D0140, D9951, D0220) provided on January 9, 2023, to January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
February 3, 2023. We also decided that the  Plan does not have to pay more for a comprehensive oral 
evaluation - new or established patient (D0150) provided on February 3, 2023. 
 
  
You asked the Plan to pay for the panoramic radiographic image (D0330), and to pay more for the 
comprehensive oral evaluation - new or established patient (D0150). You say that you were approved for a 
dental grant and had to use the provider they assigned to you. You also say that new x-rays were completed.  
The Plan denied your request. The Plan says your benefit for the panoramic radiographic image has already 
been exhausted. The Plan also says that you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider which includes the 
comprehensive oral evaluation - new or established patient. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 a comprehensive oral evaluation - new or 
established patient (D0150) provided on February 3, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory visit provided on 
December 21, 2022. 
 
You asked the Plan to waive the copayment for an in-network laboratory visit. You say that you have never had 
to pay a copayment for laboratory before. It should be covered. 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 $10 
copayment for other Medicare-covered laboratory tests that are not FIT tests. 
 
You have been asked to pay a $10 copayment for an in-network laboratory visit. This item/service falls within 
the other Medicare-covered laboratory tests that are not FIT tests 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 in-network laboratory visit provided on December 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 10, 
2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says the claim was denied as timely filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for subsequent nursing facility care was filed on November 19, 2021, which was 
rejected. The corrected claim was not submitted until January 12, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for subsequent nursing facility care provided on November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement billed to the enrollee for November 3, 2021.
You asked the Plan to pay for services billed for November 3, 2021. The Plan says the records provided do not
support the services billed. Maximus partially overturned the Plans denial and approved payment for November
10, 2021. Maximus upheld the denial for November 3, 2021. The Plan requested a reopen and stated that it was
confirmed that date of service November 10, 2021, was previously paid and not appealed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Our reviewer says that the medical records for November 3, 2021, do not include
documentation of debridement. Medicare rules for coverage of these services were not met. Therefore, we
decided the Plan does not have to pay for debridement services billed to the enrollee for November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedure for isolation of tooth with rubber dam 
(D3910) and treatment of root canal obstruction; non-surgical access (D3331) provided on July 13, 2022. 
 
You asked the Plan to pay for surgical procedure for isolation of tooth and treatment of root canal obstruction. 
You say that this should be covered. The Plan denied your request. The Plan says this is not a covered 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. 
 
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 surgical 
procedure for isolation of tooth with rubber dam (D3910) and treatment of root canal obstruction; non-surgical 
access (D3331) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and periapical radiographic 
images (D0220 and D0230) provided by an out-of-network provider on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the provider was out-of-
network, and you would have waited to make an appointment once they became a participating provider. 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 limited oral evaluation (D0140) and periapical radiographic images (D0220 and D0230) provided 
by an out-of-network provider on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on February 
16, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were referred to the specialist and 
would like the Plan to pay for the dental service. 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 $2,014 for dental services on February 9, 2023. The Plan paid $986 for dental services on 
February 16, 2023. For the year of 2023 the Plan paid $3,000 ($2,014 paid + $986 paid) for dental services; 
therefore, your benefit for the year of 2023 was exhausted on the date of service of February 16, 2023. 
Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on 
February 16, 2023.