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

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
10, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are not a hospital provider, and you are not 
required to participate in Medicare. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2023, billed with 
codes 81225, 81226, 81240, 81241, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 28, 2023, billed with codes 81225, 81226, 81240, 81241, 81306 and 81335.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower 
denture (D5140), a semi-precision abutment (D6191), and a semi-precision attachment (D6192) for tooth #21, 
#23, and #26 provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that the implants were necessary for you to eat and 
you would like to be reimbursed. The Plan denied your request. The Plan says your benefit for the dentures has 
already been exhausted. Also, the semi-precision abutment and a semi-precision attachment 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 dentures on May 3, 2022; therefore, your benefit for the immediate upper denture and 
the immediate lower denture was exhausted on the date of service of May 3, 2022. The semi-precision 
abutment and a semi-precision attachment are not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower 
denture (D5140), a semi-precision abutment (D6191), and a semi-precision attachment (D6192) for tooth #21, 
#23, and #26 provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from September 26, 2022, to 
April 26, 2023, by an OON provider. 
 
You asked the Plan to pay for the OON dental services. You say that this was a dental emergency, and you 
could not be seen by an in-network provider for months. 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 and 
implants are excluded from coverage.   
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. Additionally, dental implants and all related 
services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the dental 
services provided from September 26, 2022, to April 26, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6752) for tooth #4 provided on March 15, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the provider was advised that a bridge was 
covered, and a bridge is comprised of 3 items and not just the pontic and retainer crown. 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 retainer crown (D6792) for tooth #2 on March 15, 2023; therefore, your benefit for 
the requested item or service was exhausted on the date of service of March 15, 2023. Therefore, we decided 
that the Plan does not have to pay for a retainer crown (D6752) for tooth #4 provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service (D9310), inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230) provided on July 28, 2023. 
 
You asked the Plan to pay for consultation - diagnostic service and inhalation of nitrous oxide/analgesia, 
anxiolysis . You say that this should be covered. The Plan denied your request. The Plan says this is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
consultation - diagnostic service (D9310), inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided on July 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that the continued physical therapy is 
medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for continued 
physical therapy.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the most recent clinical documentation is dated September 16, 2022. 
There is no more recent clinical or physical therapy documentation indicating your progress with therapy, level 
of function, mobility, and your need for the services of a skilled physical therapist. Therefore, the additional 
physical therapy cannot be considered medically 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography, heart, without contrast
material, with quantitative evaluation of coronary calcium (75571) for the enrollee.

You asked the Plan to pre-approve these services. You say that the service is medically necessary. The Plan
denied your request. The Plan says that this is not covered by Medicare. Maximus overturned the Plan's denial.
The Plan requested a reopening and stated this service was not denied based on medical necessity but Medicare
coverage rules. The Plan is correct in this case. Medicare rules confirm this service is not covered by Medicare.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pre-approve a computed tomography, heart, without
contrast material, with quantitative evaluation of coronary calcium (75571) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection and application of autologous blood concentrate 
product (D7921) provided on January 19, 2023. 
 
You asked the Plan to pay for collection and application of autologous blood concentrate product. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for collection 
and application of autologous blood concentrate product (D7921) provided on January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 15, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 
87563, 87591, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on August 15, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 
87529, 87532, 87563, 87591, 87661, 87481, 87651, and 87653.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for IRF admission.  
 
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. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF as 
medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), comprehensive oral evaluation - new or established patient (D0150), 
panoramic radiographic image (D0330), resin-based composite - three surfaces, posterior (D2393), and 
prophylaxis - adult (D1110) provided on June 28, 2023, to July 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were advised by the plan that your 
dental coverage would be paid 100%. 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, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140), comprehensive oral evaluation - new or established patient 
(D0150), panoramic radiographic image (D0330), resin-based composite - three surfaces, posterior (D2393), 
and prophylaxis - adult (D1110) provided on June 28, 2023, to July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on November 15, 2022. 
 
You asked the Plan to pay for the consultation - diagnostic service. You say that you were told by the provider 
that you would not be charged for the consultation. You also say that then the office billed the insurance, to 
which the service was not covered by your Medicare dental plan. The Plan denied your request. The Plan says 
procedure code D9310 consultation is not a covered benefit under your dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on November 15, 2022.  
 
Your complaint about the consultation service being free at no charge to you is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341), and localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381) provided ion May 2, 2023, and May 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered at least 50%. 
You also say that the necessity for these procedures is a direct result of a lack of access to a lack of access to 
your dentist through the pandemic and a succession of insurance changes. The Plan denied your request. The 
Plan says these services are not covered under your dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal 
scaling and root planing - four or more teeth per quadrant (D4341), and localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided ion May 2, 
2023, and May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard testing (0114U) provided on June 26, 2023. 
 You asked the Plan to pay for the EsoGuard testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the EsoGuard testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard testing (0114U) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services (D7953, D9310 and D7956). You say that you would 
like to request reconsideration of the denied dental services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not covered 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 pre-approve the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330, D2332, and D2391) for 
tooth #9, #10, #20, #21, #23, #24, and #25, the topical fluoride varnish (D1206), the periodontal scaling and 
root planing (D4341), and the gingival irrigation (D4921) provided on July 7, 2023, July 11, 2023, and July 12, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you thought the dental services were covered 
and you would of never had them done if you knew that they were not covered. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the resin-based composite, the topical 
fluoride varnish, the periodontal scaling and root planing, and the gingival irrigation 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 pay for a resin-
based composite (D2330, D2332, and D2391) for tooth #9, #10, #20, #21, #23, #24, and #25, the topical 
fluoride varnish (D1206), the periodontal scaling and root planing (D4341), and the gingival irrigation (D4921) 
provided on July 7, 2023, July 11, 2023, and July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on June 12, 2023. 
 
You asked the Plan to pay for core buildup. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup (D2950) provided on June 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on June 5, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that you were unaware of the 
Plans policy. The Plan denied your request. The Plan says without transport there are no payable services. 
 
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 June 5, 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 services without transport received 
on June 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that the provider you are requesting to 
see is the only provider in your area that specializes in the therapy needed. The Plan denied your request. The 
Plan says there are in-network providers in your area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.