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

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for teeth #'s 6, 7, 8 and 9. 
 
You asked the Plan to pre-approve crowns-porcelain/ceramic (D2740) and core buildup (D2950) for teeth #'s 6, 
7, 8 and 9. You say that the crown and build-up are necessary due to the heavy wear into the dentin causing 
extreme sensitivity to hot and cold, fractures and teeth to be very fragile with destruction of supporting tooth 
structure making build-up necessary to restore function and supporting new crowns to avoid further fraction or 
possible tooth loss. The Plan denied your request. The Plan says this service does not meet the requirements for 
approval. 
 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 core buildup 
(D2950) 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 core buildup (D2950) for teeth #'s 6, 7, 
8 and 9. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there 
appears to be adequate coronal structure on teeth #'s 6, 7, 8 and 9 to provide adequate retention for crown 
restorations without the need for core buildups. 
 
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 core buildup (D2950) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve core buildup (D2950) for teeth #'s 6, 7, 8 and 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis -adult (D1110) provided on August 31, 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 February 17, 2023, and 
May 12, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis -adult (D1110) 
provided on August 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on June 19, 2023, by an out-
of-network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that you are contracted with the facility and the 
services were medically necessary. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no approved authorization. Also, the services rendered were not urgent or 
emergent. 
 
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 the home health visit provided on June 19, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), pulp vitality tests (D0460), 
endodontic therapy (D3310), and resin-based composite (D2330) provided on July 25, 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 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. Endodontic therapy and pulp vitality tests are not 
covered services. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140), 
pulp vitality tests (D0460), endodontic therapy (D3310), and resin-based composite (D2330) provided on July 
25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on September 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801-90 billed for date of service 
November 10, 2022. 
 
You asked the Plan to pay for procedure code 87801-90. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87801-90 is bundled into payment for code 87633. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
87801-90 is a column II code to column I code 87633. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87801-90 billed for date of service 
November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81225, 81231-59, 
81232-59, 81306-59 and 81335-59 and May 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 laboratory services billed with codes 81225, 81231-59, 81232-59, 81306-59 
and 81335-59 and May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system, a black anodized package, a custom 
footplate pad and gel for the lower extremities. 
 
You asked the Plan to pre-approve a transit system, a black anodized package, a custom footplate pad and gel 
for the lower extremities.. You say that the requested items are a medical necessity for the enrollee. The Plan 
denied your request. The Plan says the requested items do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a transit system, a black anodized package, a custom 
footplate pad and gel for the lower extremities.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on August 01, 2023. 
 
You asked the Plan to pay for a physician visit. You say that you are requesting reconsideration for the denied 
claim. 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 physician visit 
provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management service provided on June 25, 
2023. 
 
You asked the Plan to pay for evaluation and management service. You say that you are requesting 
reconsideration for the denied claim. 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 evaluation and 
management service provided on June 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341, D4342) 
provided on February 6, 2023 to February 13, 2023 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
network at the time the services were rendered. 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 periodontal scaling and root planing (D4341, D4342) provided on February 6, 2023 to February 13, 
2023 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on June 27, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 30, 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 $1,200 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 $1,200 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service May 11, 
2022.   

You asked the Plan to pay for procedure code G0480. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says payment for code G0480 is bundled into payment for 
code G0483. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0480 
is a column two code to column one code G0483 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0480 billed for date of service May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft (D7953) for tooth #31 provided on July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that there are no in-network providers in your area, 
and you would be paid back the full amount. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the bone replacement graft is not covered by the Plan and the 
guided tissue regeneration is not covered by the Plan when done with an extraction. 
 
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 bone replacement graft (D7953) is 
not among those covered under this benefit. The record shows the Plan paid for an extraction (D7210) for tooth 
#31 on July 17, 2023; therefore, the guided tissue regeneration (D4266) for tooth #31 is not a covered benefit 
when done during the same time as the extraction. Therefore, we decided that the Plan does not have to pay for 
the guided tissue regeneration (D4266) and the bone replacement graft (D7953) for tooth #31 provided on July 
17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for LTACH services for the enrollee.

You asked the Plan to provide coverage for LTACH services. You say that at the time of the appeal, transfer to
an LTACH 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 stated that
Maximus did not apply the correct criteria. The Plan notes the enrollee was admitted for incarcerated right
inguinal hernia with severe sepsis shock and respiratory failure on August 15, 2023. The enrollee's hospital stay
was complicated by acute stroke with global aphasia. The enrollee is now off all pressors, extubated, acute
kidney injury resolved, and the enrollee is on room air. Long term acute care hospitals (LTACHs) are certified
as acute care hospitals. They do not, in general, provide clinical services that are materially different than those
of short-term acute care hospitals. At the time of the appeal the enrollee was getting acute care and acute care
services have not been denied. At the time of the request, the enrollee's status is stable and improving. The
enrollee was receiving medically necessary acute and/or critical care. The enrollee did not have clinical
conditions that were not being treated in the original facility.

The Plan would have continued to cover medically necessary acute and critical care at the current
facility until the enrollee's condition was stable for transfer to an alternate level of care. Based on the records
provided, there was not care at an LTACH that was required and/or not being provided by the Plan at the
originating facility. Medicare coverage criteria for transfer were not met. Therefore, we decided that the Plan
does not have to provide coverage for long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 12, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the only chiropractic service covered by the Plan is 
manual manipulation of the spine to correct subluxation. 
 
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 chiropractic services provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical or diagnostic eye examination (92004) and an eye 
refraction (92015) provided on August 18, 2023. 
 
You asked the Plan to pay for a medical or diagnostic eye examination (92004) and an eye refraction (92015). 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says the 
records confirm you had a diagnostic eye examination on the date of service in question, not a routine eye 
exam. The Plan also says you signed consent that you are responsible to pay for the non-covered $50 refraction 
charge. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is part of a routine eye examination. The Plan 
also has a $25 copayment per Medicare-covered eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $25 copayment per Medicare-
covered eye examination. This cost sharing is a contractual obligation you agreed to pay when you enrolled in 
the Plan. Eye refractions are only covered when they are part of a routine eye examination. The record shows 
this was a diagnostic eye examination, not a routine examination. The record also shows you signed an 
agreement to pay for the non-covered eye refraction. Based on this information, we decided that the Plan's rules 
for coverage of a medical or diagnostic eye examination (92004) and an eye refraction (92015) have not been 
met. Therefore, we decided that the Plan does not have to pay for a medical or diagnostic eye examination 
(92004) and an eye refraction (92015) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on August 10, 2023.