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

 
We decided that the Plan does not have to pre-approve a crown-porcelain/ceramic (D2740) for tooth #22. 
 
You asked the Plan to pre-approve a crown-porcelain/ceramic (D2740). You say that no dental providers use 
metals. You say your dental provider said they don't use metal as it's not healthy and can cause problems. The 
Plan denied your request. The Plan says when there are multiple, clinically acceptable treatment options, the 
Plan will pay for the least expensive treatment. The Plan has approved a crown-porcelain fused to 
predominantly base metal (D2751). 
 
 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. 
 
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 a crown-porcelain/ceramic (D2740). 
Our reviewer says that the Plan's alternate treatment (D2751) is medically reasonable and necessary. Our 
physician reviewer found the Plan downgraded code D2740 to D2751. Both are crowns and will restore your 
tooth to function and will decrease the risk of fracture of the tooth. Your dentist states that tooth #22 is 
fractured and there is an open contact on both the mesial and distal surfaces causing a food trap. Your provider 
is recommending a crown to prevent further fracture of the unstable tooth structure. There was no 
documentation regarding the type of crown recommended or why D2740 is more beneficial and necessary 
compared to D2751 which has a metal coping underneath the crown. There is no mention in the clinical 
documentation of any metal allergies that would necessitate a porcelain only crown. Ultimately, a crown is 
necessary and D2751 is an alternative to D2740 and will be beneficial to you. Therefore, a crown-porcelain 
fused to predominantly base metal (D2751) is medically reasonable and necessary and expected to produce a 
satisfactory result. 
 
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  a crown-porcelain/ceramic (D2740) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a crown-porcelain/ceramic (D2740) for tooth #22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2740 and D2950) on June 12, 2023. 
 
You asked the Plan to pay for the dental services (D2740 and D2950). You say that you would like to request 
reconsideration for payment. 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 pay for the dental 
services (D2740 and D2950) on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a 2D photographic 
image (D0350), a 3D photographic image (D0351), and a cone beam (D0367) provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation has already 
been exhausted. Also, the 2D photographic image, a 3D photographic image, and a cone beam 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 a comprehensive oral evaluation (D0150) on June 20, 2022; therefore, your benefit for 
the comprehensive oral evaluation was exhausted on the date of service of June 20, 2022. The 2D photographic 
image, a 3D photographic image, and a cone beam are not covered under the Plans dental benefit. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a 2D photographic 
image (D0350), a 3D photographic image (D0351), and a cone beam (D0367) provided on October 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit and self-
administered drugs (A9270 x3) provided on August 7, 2023, to August 9, 2023. 
 
You asked the Plan to waive the copayment for the ER visit and self-administered drugs. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the ER visit and $1,013.00 liability for self-administered 
drugs. This item/service falls within the Emergency 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 copayment for an emergency room (ER) visit and self-administered drugs (A9270 x3) provided on 
August 7, 2023, to August 9, 2023.  
 
If a Medicare participating provider is billing you more than the $90 copayment and the $1,013.00 for the 
denied self-administered drugs for the date(s) of service in dispute, you can contact your Kansas City CMS 
Regional Office at 816-426-5783 to ask for assistance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on September
8, 2022.

You asked the Plan to pay for the Guardant360 test. You say that the records support medical necessity. The
Plan denied your request. The Plan says while the provider did bill with valid DEX Z-Code ZB1CW, the
procedure code 81479 billed was not listed as a recommended code. Maximus overturned the Plan's denial.
The Plan requested a reopening and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.

We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information,
we decided that Medicare rules for coverage of the Guardant360 test have not been met. Therefore, we decided
that the Plan does not have to pay for the Guardant360 test provided to the enrollee on September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on May 22, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that if you want to buy similar hearing aids 
from a vendor acceptable by the Plan, it will cost between $5,000 to $6,000. The Plan denied your request. The 
Plan says provider is not part of the vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there is 
no payable service. 
 
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 July 24, 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 without 
transport services received on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical first radiographic image (D0220) and 
intraoral- periapical each additional radiographic image (D0230) provided on June 13, 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. Therefore, we decided that the Plan does 
not have to pay for intraoral- periapical first radiographic image (D0220) and intraoral- periapical each additional radiographic image (D0230) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and to pay for a cone 
beam (D0364) and the pulp vitality tests (D0460) provided on June 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dental services should be covered 
because they were medically necessary. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year has already been exhausted. Also, the cone beam and the pulp vitality tests 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 that prior to the dates of service the Plan paid $883 for dental services. On June 16, 2023, the Plan paid 
$117 for the limited oral evaluation (D0140). For the year of 2023 the Plan paid $1,000 ($883 prior + $117 
paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on 
the date of service of June 16, 2023. The cone beam and the pulp vitality tests are not covered under the Plans 
dental benefit. Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation 
(D0140) and to pay for a cone beam (D0364) and the pulp vitality tests (D0460) provided on June 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport (A0998) 
provided on June 11, 2023. 
 
You asked the Plan to pay for ambulance response and treatment with no transport (A0998). You say that you 
were in a store, passed out, and the store called an ambulance. You also say that you do not believe you should 
be responsible for this bill. The Plan denied your request. The Plan says the services received are not covered 
by Medicare or by the Plan. 
 
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 11, 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 ambulance response and treatment with no 
transport (A0998) provided on June 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the topical application of 
fluoride varnish (D1206) provided on August 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service February 2, 2023.  
  
 
 
 
 
 
Specifically, the Plans contract states that the annual maximum dental benefit is $1,000. The record shows that 
the Plan issued payment in the amount of $108 for the dental services provided on January 20, 2023. 
Additionally, the Plan issued payment in the amount of $892 for the dental services provided on February 2, 
2023. Therefore, you have exhausted the allowable dental benefit for the services provided in this case. 
Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and the topical 
application of fluoride varnish (D1206) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D1110) on January 12, 2016. 
 
You asked the Plan to pay for the dental service (D1110). You say that you would like to request 
reconsideration for payment. 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 March 13, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental service (D1110) on January 12, 2016.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you have back pain and it cause you not to be 
stable when you stand. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport (A0998) 
provided on August 25, 2023. 
 
You asked the Plan to pay for ambulance response and treatment with no transport (A0998). You say that you 
feel that even though you were not transported, the claim should be paid. The Plan denied your request. The 
Plan says your Plan does not cover this ambulance service. 
 
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 August 25, 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 ambulance response and treatment with no 
transport (A0998) provided on August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) for tooth #14 and retainer crowns (D6740) 
for tooth #13 and #15 provided on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could use your $2,500 
limit for dental procedures. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 pontic (D6245) for tooth #12 and a retainer crown (D6740) for tooth #11; therefore, 
your benefit for the requested items or services was exhausted on the date of service of June 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a pontic (D6245) for tooth #14 and retainer 
crowns (D6740) for tooth #13 and #15 provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) provided on June 27, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025). You say that you did not ask for deluxe frames. You also 
say you only said you needed titanium frames. The Plan denied your request. The Plan says the services 
received are not covered by Medicare. 
 
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 frames and lenses are standard frames and lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that covered eyeglasses after cataract surgery 
includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not 
limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). Based on this information, we 
decided that the Plan's rules for coverage of deluxe frames (V2025) have not been met. Therefore, we decided 
that the Plan does not have to pay for deluxe frames (V2025) provided on June 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 9, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the ambulance transport was prior to the 
hospice admission. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous airway pressure device (E0601) provided on 
January 14, 2023 to February 13, 2023. 
 
You asked the Plan to pay for the continuous airway pressure device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. No clinical records were provided. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
continuous airway pressure device (E0601) provided on January 14, 2023 to February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the upper partial denture (D5213) and the lower partial denture 
(D5214) provided on July 21, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that your benefit for the dental items provided 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, substantive evidence has not been provided showing that your dental benefit 
was previously exhausted. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pay for the upper partial denture (D5213) and the lower partial 
denture (D5214) provided on July 21, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.