Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 12, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
December 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy visits. You say that you feel seeing the OON provider will 
suit your needs best; therefore, you would like the denial to be overturned. The Plan denied your request. The 
Plan says the service can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99348) provided on February 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the enrollee is an established patient for 
continued care. You say that the provider is in-network. You also say that this claim should be reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99348) provided on February 10, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular partial dentures (D5213, 
D5214). 
 
You asked the Plan to pre-approve 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 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 April 1, 2022. Therefore, 
we decided that the Plan does not have to pre-approve maxillary and mandibular partial dentures (D5213, 
D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 01, 
2023, to February 13, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that these services were 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 subsequent nursing 
facility care provided on February 01, 2023, to February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting (P-C) function of intraocular lens 
(IOL) (V2788) provided on November 3, 2022. 
 
You asked the Plan to pay for the P-C IOL. You say that you are appealing these services as you want some 
coverage for these services from the Plan. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
(P-C) function of intraocular lens (IOL) (V2788) provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological examination provided on February 8, 2023, 
by an out-of-network (OON) provider.  
 
 You asked the Plan to pay for ophthalmological examination. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-
of-network provider (a provider who is not part of the plans network) will not be 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ophthalmological examination provided on 
February 8, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on January 27, 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 and cleaning (D1110, D0120) provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided by an out-of-network provider on March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that your son made the appointment, and the 
provider told you that they were an in-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 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 (D0120) and a cleaning (D1110) provided by an out-of-network provider 
on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular and maxillary partial dentures (D5212, D5211) 
provided on September 23, 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 
mandibular and maxillary partial dentures (D5212, D5211) provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visits provided on 
February 13, 2023, to March 20, 2023. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you should not have to pay 
the copayment for the physical therapy visits. 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 $40 
copayment for each Medicare-covered physical therapy visit.  
 
  You have been asked to pay $80 for the physical therapy visits provided on February 13, 2023, and March 20, 
2023. The allowed amount is $40/visit x 2 visits = $80.  
 
You have been asked to pay $66.62, for the physical therapy visits provided on March 9, 2023, and March 13, 
2023 ($33.31/visit x 2 visits = $66.62). You were billed $33.31 per visit which is less than the standard $40 per 
visit copayment. 
 
Therefore, you have been asked to pay a total of $146.62 for the physical therapy visits ($80 + $66.62 = 
$146.62). Physical therapy visits fall within the outpatient rehabilitation services 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 the physical therapy visits provided on February 13, 2023, to March 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the surgical 
placement of implant body (D6010), a bone graft (D6104), and an extraction (D7140) for tooth #13 provided 
by an out-of-network provider on March 6, 2023.  
 
You asked the Plan to pay for the dental services. You say that the tooth extraction should be covered. The Plan 
denied your request. The Plan says the extraction was received from an out-of-network provider and is not 
covered by your supplemental benefits. Also, the denial of payment for the guided tissue regeneration, the 
surgical placement of implant body, and the bone graft is correct because they are 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. The record shows you received the extraction 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. The guided tissue regeneration, the surgical placement of implant 
body, and the bone graft are not covered under the Plans dental benefit. Therefore, we decided that the Plan 
does not have to pay for the guided tissue regeneration (D4266), the surgical placement of implant body 
(D6010), a bone graft (D6104), and an extraction (D7140) for tooth #13 provided by an out-of-network 
provider on March 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99512) provided on April 16, 2021, to 
April 30, 2021, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health 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 the 
provider does not participate with Medicare. 
 
  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services (99512) provided on April 
16, 2021, to April 30, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on October 31, 2022. We also decided the Plan 
does not have to pay for the bone replacement graft for ridge preservation - per site. 
 
You asked the Plan to waive the coinsurance for the extraction, erupted tooth. You say that you have a concern 
for the large out-of-pocket charges that you have to pay upfront. You also say that you are requesting a review 
of the invoices. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
Though 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 bone replacement graft for ridge 
preservation - per site is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for a bone replacement graft for ridge preservation - per site (D7953) provided on October 31, 
2022. 
 
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 80% 
coinsurance for out-of-network extractions. 
 
You have been asked to pay $251.20. The allowed amount for the extraction is $144.00 (20% x $144 = 
$28.80). You are responsible for an 80% coinsurance for this service. You were assessed a coinsurance of 
$115.20 and are responsible for the fees billed by the provider in excess of the allowed amount. Your liability 
of $251.20 ($136.00 + $115.20 = $251.20) is correct. This service falls within the out-of-network extractions 
and oral surgery procedures 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 an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on October 31, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (G0156). 
 
You asked the Plan to pre-approve home health 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 are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
 
  The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health aide services (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for  an oximeter purchased on May 31, 2022, due to COVID-19.

You asked the Plan to pay for  this item . You say that you had COVID-19 and this equipment was necessary.  The Plan denied your request. The Plan says the equipment is specifically stated to be non-covered by Medicare. 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. Medicare rules specifically state this equipment is not covered as it is a type of monitoring device and is not required to further treatment or apply treatment. Therefore, we decided that the Plan does not have to pay for  an oximeter purchased on May 31, 2022, due to COVID-19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown-porcelain/ceramic (D2740) provided on November 
29, 2022. 
 
You asked the Plan to pay for crown-porcelain/ceramic. 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 crown-
porcelain/ceramic (D2740) provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral comprehensive series of radiographic images 
(D0210) provided on January 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that the x-ray should be covered because you got one 
done last year that was covered. 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 a panoramic radiographic image (D0330) on December 16, 2021; therefore, your 
benefit for the requested item or service was exhausted on the date of service of December 16, 2021. Therefore, 
we decided that the Plan does not have to pay for the intraoral comprehensive series of radiographic images 
(D0210) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required tooth #'s 
19 and 29 D2950, and crown - porcelain fused to predominantly base metal tooth #19 D2751. 
 
 You asked the Plan to pre-approve the dental services represented by codes D2950 and D2751. You say that 
these services are a medical necessity. The Plan denied your request. The Plan says your benefit for the core 
buildup, including any pins when required D2950 has already been exhausted. The Plan also says crown - 
porcelain D2751 is not a covered benefit for tooth #19. 
 
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 core buildup, including any pins when required was exhausted on date of service 
July 11, 2022. The crown - porcelain fused to predominantly base metal is not a covered benefit for tooth #19. 
Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when 
required tooth #'s 19 and 29 (D2950), and crown - porcelain fused to predominantly base metal tooth #19 
(D2751).