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

 
We decided that the Plan does not have to pay for dental services provided on September 12, 2023. 
 
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 your $1,500 annual maximum 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950) provided on 
November 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work because your 
crown broke. The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service November 7, 2023. Therefore, we decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950) provided on 
November 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740) provided on July 
19, 2023. 
 
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 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 July 19, 2023. Therefore, 
we decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740) provided on July 
19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. You say that 
you have an urgent need to be seen by this specialist because you have a rare condition called urethral 
diverticulum (UD) and will need to be seen prior to surgery to remove it. The Plan denied your request. The 
Plan says the services are not urgent or emergent, and a contracted tertiary provider is available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified prosthodontic (D5899) provided on August 3, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you are not happy with the previous provider and 
they would not fic your dentures. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the unspecified prosthodontic 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 pay for an 
unspecified prosthodontic (D5899) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an oral surgical splint (21085) for the treatment
of temporomandibular joint (TMJ) syndrome.

You asked the Plan to provide coverage for dental services for treatment of TMJ. You say that at the time of
the appeal, these services were medically necessary. The Plan denied your request. The Plan says the requested
services are not covered for treatment of TMJ. 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 Medicare does not cover
routine dental services. The rules say that Medicare covers treatment for TMJ syndrome only when the
condition or symptom is medical in nature. The medical records provided do not show the diagnosis of TMJ is
directly related to a specific disease or injury. Based on this information, we decided that Medicare rules for
coverage of dental services for treatment of TMJ have not been met.

Therefore, we decided that the Plan does not have to provide coverage for an oral surgical splint (21085) for
the treatment of temporomandibular joint (TMJ) syndrome.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Nivolumab for the enrollee.

You asked the Plan to provide coverage for Nivolumab. You say that this drug is medically necessary. The
Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturn the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Nivolumab. The
medical records show the enrollee is a 61-year-old man with a diagnosis of adenocarcinoma of the pancreas. A
distal pancreatectomy and splenectomy were performed on August 30, 2021. The enrollee has been treated with
several chemotherapy regimens. A computed tomography scan of the chest, abdomen, and pelvis on August 4,
2023, demonstrated innumerable bilateral pulmonary nodules, increases in both size and number. The Plan
approved a request for Fluorouacil, Oxaplatin, and Leucovorin injection. The Plan denied Nivolumab.

Our Medical Director concluded the Plan is correct in this case. There is insufficient support in the medical
literature and guidelines for the use of Nivolumab in the requested setting, demonstrating that the drug is
expected to be safe and effective, and otherwise reasonable and necessary. Medicare coverage criteria are not
met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not
have to provide coverage for Nivolumab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown, core buildup services, and addition to a partial 
denture (D5650, D2950, D2740)  
provided on August 16, 2023, to October 25, 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 charges. 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 October 25, 2023. Therefore, we decided that the Plan does not have to pay more for a crown, core buildup services, and addition 
to a partial denture (D5650, D2950, D2740) provided on August 16, 2023, to October 25, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional acupuncture treatments (97810, 97811). 
 
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 that you have exhausted the allowable benefit for the 
acupuncture services requested in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Medicare benefit and the Plans contract states that up to 20 
acupuncture visits are covered per year for chronic low back pain. The Plan has not provided evidence that 
demonstrates this benefit has been previously exhausted. The Plan has not substantiated their denial; therefore, 
we must find in your favor. Therefore, we decided that the Plan has to pre-approve additional acupuncture 
treatments (97810, 97811).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, cleaning, and 
bitewing x-rays (D0150, D1110, D0274) provided on August 17, 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 charges. 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 a comprehensive oral evaluation, cleaning, 
and bitewing x-rays (D0150, D1110, D0274) provided on August 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via disc procedure. 
 
You asked the Plan to pre-approve the Via disc procedure. You say that you need this procedure because you 
are having a hard time walking and want to prevent having back surgery to correct your back problem. The 
Plan denied your request. The Plan says the Via disc procedure is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the Via disc procedure. Our reviewer 
says that the Via disc procedure is not medically necessary. Our physician reviewer found that the Via disc 
procedure is experimental for back pain and more research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Via disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Via disc procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 19, 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 requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 28, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a partial 
mandibular denture (D5214) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says these services have been processed 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, certain limitations apply. The record 
shows your annual dental allowance amount was exhausted on date of service August 23, 2023. Therefore, we 
decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a partial mandibular 
denture (D5214) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 1, 2023, through August 31, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider.  
  
 
 
However, in this case, you purchased a gym membership from an out-of-network provider. Additionally, the 
Plans contract states that enrollees receive $325 every three months on a Flex card that may be utilized for 
qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. Therefore, we decided that 
the Plan does not have to issue reimbursement for the health club membership provided from January 1, 2023, 
through August 31, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285) provided on October 15, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like this claim to be 
reviewed for payment. The Plan denied your request. The Plan says that this claim has been denied as a 
duplicate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the records do not support the Plan's denial in this case. 
Specifically, the Plan has not provided any evidence to support their claim that code 99285 was duplicate 
billing. This means that the Plan has not provided a valid reason for denying payment of the emergency 
department visit. It is the burden of the Plan to substantiate their denial with evidence. In this case, the denial 
has not been substantiated. Therefore, we decided that the Plan has to pay for the emergency department visit 
(99285) provided on October 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5110, D5120) 
provided on August 14, 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 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 July 16, 2021. Therefore, 
we decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5110, D5120) 
provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 4, 2023. 
 
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 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 $1,200 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on October 3, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on October 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care for the enrollee. You say that at the time of the appeal,
IRF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that
Maximus did not apply the correct criteria. The Plan noted that the medical records show the enrollee's ability
to participate in intensive therapy was described as limited by the hospital therapist due to lethargy,
encephalopathy, and the need for total assistance to move.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. Based
on the medical records provided at the time of the appeal, the enrollee was not expected to have the ability to
participate in at least 3 hours of therapy daily for 5 days a week. Medicare rules for coverage of IRF care were
not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87801, 87511, 87640, 87798, 87500,
87653 and 87481) provided to the enrollee on February 23, 2023.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that
the laboratory services were incorrectly coded and not in accordance with Medicare guidelines.

The Plan states that this was a Mol Dx panel and a "not otherwise classified" (NOC) code should billed with
one unit of service and not unbundled with -59 modifiers. A test panel cannot be unbundled and billed as
individual components although the test reports multiple individual pathogens and/or targets. The billing
laboratory did not include any medical records with the claim. The services billed with the -59 modifier were
reviewed and denied as the services were included and were not separate and distinct services. The Plan
notified the billing laboratory of the denials for the claim on March 7, 2023. In the denial letter, the provider
was informed that the codes billed were incorrect and there was a more appropriate NOC code that should be
billed.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the
amount of payment. Based on the records provided, there was insufficient documentation to show the Medicare
rules for payment of these services were met. In addition, there were errors on the claim submitted for which
the Plan has given direction for correction. Therefore, we decided that the Plan does not have to pay for
laboratory services (87801, 87511, 87640, 87798, 87500, 87653 and 87481) provided to the enrollee on
February 23, 2023.