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

 
We decided that the Plan does not have to pay for a fixed partial denture sectioning (D9120) provided on 
February 26, 2023. 
 
You asked the Plan to pay for D9120. You say that you were unaware that this was not covered. The Plan 
denied your request. The Plan says D9120 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 fixed 
partial denture sectioning (D9120) provided on February 26, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on September 
19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that you need a new bridge, and you would like 
the Plan to approve the dental service. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because the partial upper denture 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical radiographic image (D0230), the 2D 
photographic images (D0350), and the resin-based composites (D2330 and D2394) for tooth #21 and #27 
provided on August 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that they were only going 
to do 2 fillings and then they ended up doing 4. The Plan denied your request. The Plan says your benefit for 
the periapical radiographic image and resin-based composites has already been exhausted. Also, the denial of 
payment for the 2D photographic images 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. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for 1 periapical radiographic image and 2 resin-based composites on August 27, 2021; 
therefore, the enrollees benefit for the periapical radiographic image and the resin-based composites was 
exhausted on the date of service of August 27, 2021. The 2D photographic images are not covered under the 
Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the periapical radiographic 
image (D0230), the 2D photographic images (D0350), and the resin-based composites (D2330 and D2394) for 
tooth #21 and #27 provided on August 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on 
September 01, 2022, to September 09, 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 September 01, 2022, to September 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided by an out-of-network provider 
on January 10, 2023. 
 
You asked the Plan to pay for the dental service. You say that you thought the provider was an in-network 
provider and it was a mix up with the provider names. 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 a cleaning (D1110) provided by an out-of-network provider on January 10, 2023.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the deductible for the mammogram provided on July 22, 2022.
You asked the Plan to waive the deductible for the mammogram. You say that this was ordered by your doctor
due to previous breast cancer diagnosis. The Plan denied your request. The Plan says that that this is the correct
cost sharing amount for a diagnostic mammogram.
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 does not say in clear and accurate terms
that you will be responsible for the deductible for mammograms.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a
deductible for mammograms. The Plan contract does not clearly state that a deductible will apply for a
diagnostic mammogram. The EOC states that cost sharing may apply but does not clearly indicate when or
when it would not apply. This means that the Plan did not follow Medicare rules for disclosure of cost sharing
information. Therefore, we decided that the Plan has to waive the deductible for the mammogram provided on
July 22, 2022.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on 
December 27, 2022, to December 29, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you say you were 
billed for an outpatient hospital care but was inpatient for two days. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $95 copayment for outpatient hospital observation. This item/service falls within 
the outpatient hospital observation 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 
outpatient hospital observation provided on December 27, 2022, to December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a mandibular partial denture (D5214) provided on 
December 22, 2022. 
 
You asked the Plan to pay more for a mandibular partial denture. You say that you would like to be reimbursed 
for what you paid out of pocket. The Plan denied your request. The Plan says they have paid the correct amount 
and the remaining charges are your responsibility.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 30% 
of the cost for a denture received from an in-network provider. Therefore, we decided that the Plan does not 
have to pay more for a mandibular partial denture (D5214) provided on December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (CGM), supplies and accessories provided on January 12, 2023. 
 
 You asked the Plan to pay for the supply allowance supplies and accessories . You say that you would like the 
medical records to be reviewed and the claim to be reprocessed and paid. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 24, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for supply allowance for 
nonadjunctive, nonimplanted continuous glucose monitor (CGM), supplies and accessories provided on 
January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050) purchased on 
February 6, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider, without prior authorization.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that authorization rules apply 
for out-of-network covered hearing items/services. However, the hearing aids in this case were purchased from 
an out-of-network provider, without prior authorization. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5050) purchased on February 6, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $800 cost share charged for skilled nursing
facility (SNF) services provided from June 1, 2022, to June 14, 2022.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The
Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial for insufficient information in the case file. The Plan requested a reopen and provided additional
information to show that you were in a skilled nursing facility (SNF) from May 16, 2022, to June 14, 2022,
with no breaks in service. The Plan provided the records and claims reflecting these dates. The records show
day 20 of the SNF stay fell on July 5, 2022. You were discharged on June 14, 2022. Therefore, per the Plan
contract, you would be responsible for this cost share.
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 contract with the Plan clearly says that you must pay $100 a day for SNF services beginning on day 20 of
an approved stay. 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 cost share charged for skilled nursing facility (SNF) services provided
from June 5, 2022, to June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a lipid panel provided on October 26, 2022.
You asked the Plan to pay for these services . You say that you have had this test twice before in the last five
years and it was covered by the Plan. The Plan denied your request. The Plan says this cost sharing was
charged correctly. Maximus overturned the Plans denial as Plan directed care. The Plan requested a reopen and
stated that you were told prior to the service being rendered about the coverage requirements. The Plans
provided documentation to show you had a paid claim for the same lipid panel (80061) under this Policy for
date of service October 22, 2021. The Plan will not pay for the service again until 2026.
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 this test is only covered every 5 years. Coverage for this service was not available on the date
in question. Therefore, we decided that the Plan does not have to pay for a lipid panel provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on February 01, 2023. 
 
You asked the Plan to pay for home evaluation 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 home evaluation visit 
provided on February 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7140)  provided on January 23, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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 an extraction (D7140)  provided on January 
23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5259) purchased on  
June 30, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were not purchased from the Plan's select hearing aid provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when purchased from the Plans select hearing aid provider. However, the hearing aids in this 
case were not purchased from the Plans select hearing aid provider. Therefore, we decided that the Plan does 
not have to issue reimbursement for the hearing aids (V5259) purchased on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower 
denture (D5120), and extractions (D7140) for tooth #18, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are an 
emergency, and they need to be done. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because the dentures and the extractions 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. 
 
  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 pre-approve a 
complete upper denture (D5110), a complete lower denture (D5120), and extractions (D7140) for tooth #18, 
#21, #22, #23, #24, #25, #26, #27, #28, #29, and #31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on March 24, 2022. 
 
You asked the Plan to pay for wound care 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 wound care services 
provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied denture 
because you need it. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the partial lower denture 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5214).