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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
prophylaxis (D1110) and periapical first x-ray (D0220) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. 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 the problem focused limited oral evaluation (D0140), prophylaxis (D1110) and periapical first x-ray 
(D0220) provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070-59 billed for date of service August 
16, 2023. 
 
You asked the Plan to pay for procedure code 99070-59. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99070-59 is considered bundled and 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 procedure code. 
 
We find that procedure code 99070-59 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99070-59 is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99070-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99070-59 billed for date of service August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) and 2D 
oral/facial photographic images (D0350 x 3) provided on August 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you assumed everything would be covered 
because the provider accepts your insurance, and you were not aware of the benefit 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 dates of service June 15, 2022, and 
August 17, 2023. Therefore, we decided that the Plan does not have to pay for the complete series of x-ray 
images (D0210) and 2D oral/facial photographic images (D0350 x 3) provided on August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mastectomy bra provided on October 14, 
2022. 
 
You asked the Plan to waive the coinsurance for a mastectomy bra. You say that there was no other way for 
you to get your bra, as the facility you were using stopped distributing breast products. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for a mastectomy bra. This item/service falls within the 
prosthetic devices and related 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. The total you owe is $35.81 ($179.04 x 20% = $35.81). Therefore, we decided 
that the Plan does not have to waive the coinsurance for a mastectomy bra provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for SSBCI benefits.

You asked the Plan to provide coverage for SSBCI benefits. The Plan denied your request. Maximus
overturned the Plans denial for a lack of medical records in the case file. The Plan requested a reopen and
provided the required medical records.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules and Plan contract rules
state for coverage for supplemental SSBCI benefits, the medical records must show specific criteria for
coverage are met. Based on the medical records provided, you do not meet the criteria required for approval of
these supplemental benefits. Therefore, we decided that the Plan does not have to provide coverage for special
supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for the transcutaneous electrical nerve stimulator
(TENS) device (E0730) provided to the enrollee on December 3, 2021.

You asked the Plan to pay for this device. You say that this claim should be paid. The Plan denied your request.
The Plan says this equipment is not covered by Medicare when prescribed in a chiropractic setting. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that the only chiropractic
service Medicare covers is manual manipulation of the spine to correct a subluxation. Medicare does not cover
a TENS unit provided in a chiropractic setting. Therefore, we decided that the Plan does not have to pay for to
pay for the transcutaneous electrical nerve stimulator (TENS) device (E0730) provided to the enrollee on
December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the resin-based composite fillings
rendered on February 6, 2023.

You asked the Plan to waive the coinsurance for these services. The Plan denied your request. The Plan this
cost share was applied appropriately. Maximus overturned the Plans denial. The Plan requested a reopen and
provided additional information.

The Plan is correct in this case. Medicare generally does not cover dental services. 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 these services with a 50% coinsurance. This cost sharing is a contractual obligation the enrollee agreed
to pay when they enrolled in the Plan.

Therefore, we decided that the Plan does not have to waive the coinsurance for the resin-based composite
fillings rendered on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
July 31, 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 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 2D 
oral/facial photographic images (D0350) provided on July 31, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 provided on August 15, 2023. 
 
You asked the Plan to pay for procedure code P9603. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure code P9603 provided on August 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided on June 
24, 2023, to June 28, 2023. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you do not agree with 
the cost sharing. 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 10% 
coinsurance for each Medicare-covered hospital stay. 
 
You have been asked to pay 10% coinsurance for an inpatient hospital stay. This item/service falls within the 
each Medicare-covered hospital stay 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 you owe is $931.87 ($9,318.73 allowed amount x 10% = $931.87). 
Therefore, we decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay 
provided on June 24, 2023, to June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #29 provided on February 
15, 2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan verified that the dental service would be 
100% covered so the bill must be an error. The Plan denied your request. The Plan says the denial of payment 
for this service is correct because the core buildup is not covered by the Plan. Also, it was verified that you did 
not contact the Plan prior to the date of service to verify 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #29 provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service July 31, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that you would like the Plan to reconsider their 
denial of payment. 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 88377 is 5. The MAI value for this code is 3. You billed 6 additional 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 88377 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88377 billed for date of service July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames (V2020), bifocal lenses (V2203), 
photochromatic tint (V2744), anti-reflective coating (V2750), and lenses (V2783) provided on August 29, 
2023. 
 
You asked the Plan to pay more for frames, bifocal lenses, photochromatic tint, anti-reflective coating, and 
lenses. You say that you have not been to the eye doctor for two years. You also say you were understanding 
that you were allowed $50 or something similar each year. The Plan denied your request. The Plan says this 
benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers reimbursement for up to $125 every calendar year towards the purchase of 
eyeglasses. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan reimburses up to $125 towards the 
purchase of eyeglasses or contact lenses. The record shows this benefit was exhausted on August 29, 2023. 
Specifically, the record shows that the Plan paid the provider the $125 directly. Based on this information, we 
decided that the Plan's rules for coverage of frames, bifocal lenses, photochromatic tint, anti-reflective coating, 
and lenses have not been met. Therefore, we decided that the Plan does not have to pay more for frames 
(V2020), bifocal lenses (V2203), photochromatic tint (V2744), anti-reflective coating (V2750), and lenses 
(V2783) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays and bitewing x-rays (D0220, D0270) 
provided on August 31, 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 your benefit for the bitewing x-rays has already been exhausted. 
Coverage for the intraoral x-rays 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, certain limitations apply. The record 
shows your benefit for bitewing x-rays was exhausted on date of service February 16, 2023. Moreover, this 
benefit does not include intraoral x-rays. Therefore, we decided that the Plan does not have to pay for intraoral 
x-rays and bitewing x-rays (D0220, D0270) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you  had previously gone to a dentist closer to 
your home, but he was out-of-network. You also say that you found a different dentist that is in-network. You 
also say that the first thing a new dentist wants from a new patient is 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 May 18, 2022. Therefore, 
we decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #12 and #4, a retainer crown 
(D6740) for tooth #13, and a crown (D2710) for tooth #12, #13, #14, and #15. 
 
You asked the Plan to pre-approve the dental services. You say that without the approval of the dental work 
you are not able to eat, and it has caused you to lose weight. The Plan denied your request. The Plan says your 
benefit for the pontics and retainer crown has already been exhausted. Also, the requested crown is not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a pontic (D6245) for tooth #30 and a retainer crown (D6740) for tooth #15, #29, 
and #31 on March 22, 2023, and October 25, 2023; therefore, your benefit for the pontics and retainer crown 
was exhausted on the date of approval of October 25, 2023. The requested crown is not covered under the 
Plan's dental benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for 
tooth #12 and #4, a retainer crown (D6740) for tooth #13, and a crown (D2710) for tooth #12, #13, #14, and 
#15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87491, 87563, 87640, 87653, 
87798, 87641, and 87500) provided on July 27, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500) 
provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization indicates that the enrollee 
does not use insulin or have a history of problematic hypoglycemia. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hotel lodging provided from May 7, 2023, to 
May 11, 2023. 
 
You asked the Plan to reimburse you for the lodging. You say that the enrollee was flown out to a facility on 
the other side of the country. You say that the enrollee saw a neurologist for their condition. You also say that 
the hospital covered the airfare but not the lodging. The Plan denied your request. The Plan says the lodging 
this case is not related to transplant services and therefore are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file, and Medicare rules. The records do not support that the lodging was related to transplant 
services. Therefore, we decided that the Plan does not have to reimburse you for the hotel lodging provided 
from May 7, 2023, to May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), and a panoramic radiographic image (D0330) 
provided by an out-of-network provider on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you made an appointment with a provider that 
was on the Plan's list and the services needs to be paid for. 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. Also, it was verified prior to the date of service you were given 3 providers that were in-network, and 
the rendering provider was not 1 of the participating providers. 
 
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 comprehensive oral evaluation (D0150), the intraoral radiographic images (D0220 and D0230), 
bitewings (D0274), and a panoramic radiographic image (D0330) provided by an out-of-network provider on 
July 25, 2023.