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

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on February 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told you could have these x-rays. 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, 20221. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) 
provided on February 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 14, 
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 services denied correctly as they do not fall 
within your dental 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 a limited 
oral evaluation (D0140) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on December 14, 2022. 
 
You asked the Plan to pay for debridement of nails. You say that you are requesting a reconsideration of the 
denied charges. 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 debridement of nails 
provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal
implant (D6010).
You asked the Plan to pre-approve these services. You say that this service is necessary, and you require the
Plan's health to pay for it. The Plan denied your request. The Plan says that this service is not covered under
your benefits. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the
Schedule of Cost Sharing.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve 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 pre-approve the surgical placement
of implant body: endosteal implant (D6010).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0496, Q5002) provided from 
July 12, 2022, to August 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services (G0496, Q5002) provided from July 12, 
2022, to August 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on February 
24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that you are requesting a 
reconsideration of the denied charges. 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 February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulation management provided on February 07, 2023. 
 
You asked the Plan to pay for anticoagulation management. 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 anticoagulation 
management provided on February 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) for the
enrollee.
You asked the Plan to pre-approve Sprint peripheral nerve stimulation (PNS). You say that this treatment is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Sprint PNS
system. The Maximus Physician Reviewer determined that Medicare rules say that Sprint PNS systems are
only covered for certain indications. Therefore, we decided that the Plan has to pre-approve Sprint peripheral
nerve stimulation (PNS). The Plan requested a reopen and stated that "Although there are recent small studies
looking at the proposed theory of sustained relief following a short-term percutaneous PNS treatment for
multiple pain indications, there are limitations of existing evidence to help support the proposed mechanistic
theories, including independent investigations, larger cohorts, more active or sham controlled studies, and more
consistent periods of long-term follow-up. Medicare does not cover unproven and not medically necessary
procedures due to insufficient evidence of efficacy. More studies are needed to show sixty (60) day PNS
SPRINT device is effective." The enrollee was a then 76-year-old woman with chronic intractable right
shoulder pain. She has tried physical therapy, a home exercise program, and takes opiates (Norco) for pain.
She cannot tolerate NSAIDs. The Plan is correct in this case. The Evidence-Based Guidelines from the
American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the
Treatment of Chronic Pain in 2022 states, "PNS may offer modest and short-term pain relief, improved
physical function, and better quality of life for chronic hemiplegic shoulder pain." There is insufficient
evidence in the medical literature at this time supporting the use of the Sprint PNS system in the management
of chronic shoulder pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Sprint peripheral nerve stimulation (PNS). Medicare coverage criteria are not
met. Therefore, we decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation
(PNS) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on February 9, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 27096 which was also billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code J3490 provided on February 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 12, 2023, to 
February 13, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the prescribed drugs are medically 
necessary. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 pay for self-administered drugs provided 
from February 12, 2023, to February 13, 2023.  
 
Benefits for self-administered drugs 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 an extraction (D7140) for tooth #11 provided by an out-of-
network provider on November 2, 2022.  
 
You asked the Plan to pay for the dental service. You say that the in-network provider said they could not do 
the procedure, so you had to see an out-of-network 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 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 an extraction (D7140) for tooth #11 provided by an out-of-network provider on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interm implant crowns (D6085) provided on January 19, 
2023. 
 
You asked the Plan to pay for D6085. You say that this dental work was not cosmetic but was medically 
necessary. The Plan denied your request. The Plan says D6085. 
 
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 interm 
implant crowns (D6085) provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355) provided on February 27, 
2023. 
 
You asked the Plan to pay for a full mouth debridement. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered 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 pay for a full 
mouth debridement (D4355) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
26, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered, and the 
provider is an in-network provider. 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 the Plan paid for periodontal maintenance on September 16, 2022, with the benefit level once every 6 
months you would not be eligible for another periodontal maintenance until March 16, 2023. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 26, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride (D1208) and unspecified 
preventive procedure (D1999) provided on August 1, 2022. 
 
You asked the Plan to pay for topical application of fluoride and unspecified preventive procedure. 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 topical 
application of fluoride (D1208) and unspecified preventive procedure (D1999) provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home COVID-19 test kits purchased on August 15, 2022.
You asked the Plan to pay for these tests. You say that the Plan should pay for these testing kits. The Plan
denied your request. The Plan says the Medicare rules stated enrollees in a Plan, would
not get this testing covered as a Plan benefit. Maximus overturned the Plans denial. The Plan requested a
reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say enrollees cannot
submit a claim for these tests to Medicare or their plan (unless covered by a supplemental benefit) for
reimbursement. These test kits were not covered supplementally by your Plan on the date of service.
Therefore, we decided that the Plan does not have to pay for home COVID-19 test kits purchased on August
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 04, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home 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 domiciliary or rest home 
visit provided on November 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 19, 2022. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 You asked the Plan to pre-approve the additional routine transportation mileage. You say that you are 
requesting additional mileage for a surgery scheduled in July 2023. The Plan denied your request. The Plan 
says you are requesting an additional 37 miles for a total of 87 miles. Your benefit only allows 50 miles. You 
have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation mileage. Based on this information, we decided that you have exhausted the 
Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs provided on 
December 12, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were under the 
impression that the treatment was fully 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 20% 
coinsurance for chemotherapy drugs. 
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs. This item/service falls within the 
chemotherapy drugs 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 chemotherapy 
drugs provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 13, 2023. 
 
You asked the Plan to pay for domiciliary or rest home visit. 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 domiciliary or rest home 
visit provided on January 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on August 
22, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. 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 subsequent nursing 
facility care visits provided on August 22, 2022.