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

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered because you 
went to this provider for a second opinion. 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 February 27, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on January 3, 2023, by an out-of-network (OON) provider. 
 
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 (D0120, D1110) provided on January 3, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided 
on October 24, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliances provided on October 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not have to pay because the services were medically necessary. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on October 24, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) x3 provided on December 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you called in-network providers, but no 
one could see you, so you had to use an out-of-network provider. 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. This benefit includes the 
requested extraction, erupted tooth or exposed root but is limited to two procedure codes per calendar year. The 
Plan contract says that enrollees must pay 50% coinsurance in-network and 100% out-of-network for 
extractions (pulling teeth). 
 
The allowed amounts for the covered dental services total $180, resulting in a coinsurance amount of $90 
($180 x 50% = $90), and a Plan payment of $90. 
 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
We looked at the file, the Plans rules, and Medicares rules. You received covered extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) x2 at the in-network rate on December 20, 2022. 
Therefore, this benefit was exhausted. Therefore, we decided that the Plan does not have to pay more for 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) x3 provided on December 
20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and a cone beam 
(D0364) provided on January 6, 2023. 
  You asked the Plan to pay for the dental services. You say that the x-ray was needed for diagnostics reasons, 
and you have contacted the Plan multiple times to clarify that. The Plan denied your request. The Plan says 
your benefit for the limited oral evaluation has already been exhausted. Also, the denial of payment for the 
cone beam is correct because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on the date of service of January 4, 2023. The 
cone beam is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) and a cone beam (D0364) provided on January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954) 
provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
prefabricated post and core in addition to crown (D2954) provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing 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 27, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2790), core buildup (D2950) and gingival 
irrigation with a medicinal agent (D4921 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you needed to see a new provider because 
the first provider could not properly fix your dental issues. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 17, 2022. 
Additionally, your provider may resubmit the required missing information for D4921 and request approval. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2790), core buildup (D2950) and 
gingival irrigation with a medicinal agent (D4921 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an in-house dental plan provided on September 21, 2021. 
 
You asked the Plan to pay for the in-house dental plan. You say that you are asking for reconsideration to allow 
reimbursement. You also say that your mother had no idea she needed to send in this paperwork. The Plan 
denied your request. The Plan says additional dental insurance plans or in-house dental plans are not listed as a 
covered dental service, and therefore would not have been eligible for reimbursement had the claim been 
submitted in a timely manner. For dental benefits in 2021, codes and benefit limitations are described on pages 
121-129. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the in-house dental plan was not filed until January 9, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an in-house dental plan provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown, mandibular partial denture, and 
core buildup services (D5214, D2740, D2950) provided on February 14, 2023. 
 
  You asked the Plan to waive the coinsurance 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 the cost-sharing applied 
correctly based on the services provided. The core buildup 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 core buildup services are not 
among those covered under this benefit. 
 
You have been asked to pay a 50% coinsurance for a crown and mandibular partial denture (D5214, D2740). 
These services fall 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 coinsurance 
for a crown, mandibular partial denture, and core buildup services (D5214, D2740, D2950) provided on 
February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on August 17, 
2022. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that this is supported in the records. 
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 chiropractic 
manipulative treatment provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 04, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 laboratory testing 
provided on January 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an E0466 home ventilator for the enrollee.
You asked the Plan to provide coverage for an E0466 home ventilator for the enrollee. You say that at the time of the appeal, this ventilator was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator (E0466). The enrollee was a then 69-year-old man with medical diagnoses that included severe COPD with chronic respiratory failure, obstructive sleep apnea, multiple sclerosis, thoracic restrictive disorder, diabetes, coronary artery disease, and congestive heart failure. The provider documents that the enrollee will require nocturnal volume ventilation with some daytime use. The enrollee will require AVAPS-AE. The documentation is insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. Products classified as code E0466, when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode.
Requests for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in the Medicare RAD policy will be denied as not reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for an E0466 home ventilator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portible knee x-ray provided on November 07, 2022. 
 
You asked the Plan to pay for a portible knee x-ray. You say that this was medically necessary and should be 
covered. 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 a portible knee x-ray 
provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on September 26, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot drop braces (L4398 x2) provided on January 11, 
2023. 
 
You asked the Plan to pay for the foot drop braces. You say that these braces were purchased online and are 
medically necessary. You also say that the braces should be covered according to your Evidence of Coverage. 
The Plan denied your request. The Plan says the treating provider does not accept Medicare, and is not included 
in Medicare's Supplier Directory as a certified durable medical equipment provider. The Plan also says that 
there were providers available for you to have received services that were certified within 25 miles of you. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the foot drop braces have not been met. This provider is not part of the Medicare program and is 
not payable. Therefore, we decided that the Plan does not have to pay for the foot drop braces (L4398 x2) 
provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the visual field assessments with technical 
support provided from May 21, 2022, to December 17, 2022. 
 
You asked the Plan to waive the copayments for the visual field assessments. You say that you want to be 
reimbursed for the eight billed dates of service The Plan denied your request. The Plan says the claim was 
reprocessed, and you are responsible for a $50 copayment for each date of service. 
 
 
 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 $50 
copayment for services for the diagnosis and treatment of diseases and injuries of the eye.  
 
You have been asked to pay a $50 copayment for the visual field assessments on each date of service. This 
service falls within the vision 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. Therefore, we decided that the Plan does not have to waive the copayments for 
the visual field assessments with technical support provided from May 21, 2022, to December 17, 2022.