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

 
We decided that the Plan does not have to waive the cost-sharing for extractions for teeth #30 and #31 and cone 
beam computed tomography (CT) scan (D7140, D0380) provided on April 18, 2023. 
 
  You asked the Plan to waive the cost-sharing 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 cone beam CT scans 
denied correctly as they do not fall within your dental benefits. The cost-sharing for extractions applied 
correctly. 
 
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, cone beam CT scans are not among 
those covered under this benefit. 
 
You have been asked to pay a 50% coinsurance for extractions. This item/service falls within the Dental 
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 cost-sharing for extractions for teeth #30 
and #31 and cone beam computed tomography (CT) scan (D7140, D0380) provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and a cleaning 
(D1110) provided by an out-of-network provider on August 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were seen by your dentist and the 
Plan should cover 70% of the dental services. 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. Also, the proper cost share was applied. 
 
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 total amount billed for the periodic oral evaluation (D0120) was $70 and the total allowed amount was $30 
leaving a difference of $40 ($70 billed - $30 allowed). The coinsurance amount was $9 ($30 allowed x 30% 
coinsurance). The total billed amount for the cleaning (D1110) was $122 and the total allowed amount was $40 
leaving a difference of $82 ($122 billed - $40 allowed). The total coinsurance amount was $12 ($40 allowed x 
30% coinsurance). The total enrollee liability was $143 ($40 difference + $9 coinsurance + $82 difference + 
$12 coinsurance). 
 
You have been asked to pay the coinsurance amount and 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 the periodic oral 
evaluation (D0120) and a cleaning (D1110) provided by an out-of-network provider on August 7, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on July 7, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that code G0483 is bundled into payment for 
code 80305. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has withdrawn the rule stating that code 
G0483 is bundled into code 80305. Code G0483 is now separately payable from code 80305 in accordance 
with the bulletin that CMS published on its website along with the 2023 Q4 NCCI files.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0483 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0483 provided on July 7, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on August 8, 2023, and billed with codes 87481, 87500, 87640, 87652, and 87798. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not 
appropriate.  
 
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 urine polymerase chain reaction (PCR) panel testing provided on August 8, 
2023, and billed with codes 87481, 87500, 87640, 87652, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 29, 2023, by 
an out-of-network (OON) provider.  
 You asked the Plan to pay for OON services. You say that the appointment was scheduled by the facility where 
the enrollee was residing. The Plan denied your request. The Plan says that their original decision to deny 
payment was correct. 
 
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 services provided on August 29, 
2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy provided on May 15, 2023. 
 
You asked the Plan to pay for the laparoscopy. You say that you are requesting reconsideration for the service 
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 the laparoscopy 
provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the obesity counseling services provided on 
December 8, 2021, and Phentermine provided on June 3, 2022. 
 
You asked the Plan to reimburse you for the obesity counseling services on December 8, 2021, and 
Phentermine. You say that you would like to be reimbursed for these services. The Plan denied your request. 
The Plan says the reimbursement request for December 8, 2021, was not submitted by the required deadline. 
The Plan says that the reimbursement request for Phentermine cannot be approved. The Plan also says that this 
benefit is only for the program and does not include supplies. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the weight loss management services have not been met. The record shows that the claim for the 
obesity services on December 8, 2021, was not submitted until March 31, 2023, after the required date. 
Additionally, the Evidence of Coverage clearly states that the weight management benefit only provides 
coverage for programs, and not supplies, such as Phentermine. Therefore, we decided that the Plan does not 
have to reimburse you for the obesity counseling services provided on December 8, 2021, and Phentermine 
provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on September 06, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was 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 the drug testing 
provided on September 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 13, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have provide coverage for a vacuum pump, residual limb volume
management and moisture evacuation system (L5781).

You asked the Plan to provide coverage for a vacuum pump. The Plan denied your request. The Plan says the
vacuum pump is not covered by Medicare. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not use the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover investigational
devices. At the time of the appeal, the use of vacuum pumps for residual limb volume management and
moisture evacuation systems by amputees is unproven and not medically necessary due to insufficient evidence
of safety and/or efficacy. Medicare rules for coverage of the requested vacuum pump have not been met.
Therefore, we decided that the Plan does not have to provide coverage for a vacuum pump, residual limb
volume management and moisture evacuation system (L5781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia-
first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute 
increment (D9243), and alveoloplasties in conjunction with extractions-one to three teeth or tooth spaces, per 
quadrant (D7311 x 3). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested anesthesia services are not medically 
necessary. Additionally, an alveoplasty is not a covered benefit under the supplemental dental policy.  
 
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 Plan covers anesthesia 
services when the services are medically necessary and reasonable.  
 
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 these services. Our reviewer says that 
the requested anesthesia services are not medically necessary. Our physician reviewer found that there was a 
clinical note from your visit with your doctor, and a medical clearance letter for dental treatment which stated 
that no special precautions were necessary. There was no clinical documentation provided noting that you 
cannot tolerate a local anesthetic, or why sedation is necessary. There were also no narratives or clinical notes 
from your dental provider or oral surgeon included. Additionally, there were no x-rays or photos included in 
the review. Based on the lack of supporting information the requested services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the anesthesia services have not been met. Additionally, an alveoplasty is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve intravenous moderate 
(conscious) sedation/analgesia-first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia-
each subsequent 15 minute increment (D9243), and alveoloplasties in conjunction with extractions-one to three 
teeth or tooth spaces, per quadrant (D7311 x 3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power scooter (K0801). 
 
You asked the Plan to pre-approve a heavy-duty power scooter. You say that a regular power scooter is too 
small for you. You say that your feet hang over and it is not powerful enough. You also say that you do not feel 
secure as it has tipped over before. The Plan denied your request. The Plan says the requested POV does not 
meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operative vehicle (POV) is covered if 
the beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class POV. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty power scooter have not been met. Specifically, the file does not support that the 
enrollee's weight is at least 285 pounds. Therefore, we decided that the Plan does not have to pre-approve a 
heavy-duty power scooter (K0801).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on 
November 21, 2022, to December 02, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you were not told you 
would have such large copayments. 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 $200 
copayment for inpatient hospital care.  
You have been asked to pay a $200 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $400 for the inpatient hospital stay ($200 copayment 
+ $50 x 4 days = $400). You have not been charged for the day you were discharged. Therefore, we decided 
that the Plan does not have to waive the copayment for an acute inpatient stay provided on November 21, 2022, 
to December 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 4, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order or proof of delivery which support medical necessity for 
the supplies provided in this case. There is no valid physicians order. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on July 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on August 02, 2023. 
 
You asked the Plan to pay for the debridement. You say that you are requesting reconsideration for the service 
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 the debridement 
provided on August 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on July 27, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you went to your dentist office for a 6-month 
cleaning, and you did not ask the doctor to come into the room. 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 periodic oral evaluation (D0120) on January 26, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of January 26, 2023. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service April 28, 2023. Specifically, the 
Plans contract states that a lower partial denture is covered once every 60 months.  
  
 
 
 
You previously received this dental item on April 28, 2023, less than 60 months prior, which was paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for the requested dental item in this case. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (26020, 26951, 10061, 26080) provided on 
May 15, 2023. 
 
You asked the Plan to pay for the surgical services. You say that the services were emergent and medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes 26020, 26951, 10061, & 26080 are not supported in the medical record. Specifically, 
the codes billed were not billed with the required GJ modifier to denote emergent services performed by an 
opt-out provider. Based on this information, we decided that Medicare rules for coverage of the surgical 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
(26020, 26951, 10061, 26080) provided on May 15, 2023.