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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), dental cleaning 
(D1110), and the unspecified preventive procedure, by report (D1999) provided on August 30, 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental 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 the 
comprehensive oral evaluation (D0150), dental cleaning (D1110), and the unspecified preventive procedure, by 
report (D1999) provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary denture relining and clasp addition 
to existing partial denture (D5660, D5750). 
 
You asked the Plan to pre-approve 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 pre-approve 
complete maxillary denture relining and clasp addition to existing partial denture (D5660, D5750).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 4, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. 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 September 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 21, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on September 5, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring services provided on March 
31, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring services. You say that the enrollee was in a 
nursing home at the time the services were rendered. 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 remote physiologic 
monitoring services provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the lower and sacral spine (72100), the office 
visit (99203), and the manual therapy techniques (97140) provided by a chiropractor on July 13, 2023, to, 
August 15, 2023. 
 
You asked the Plan to pay for the x-ray of the lower and sacral spine (72100), the office visit (99203), and the 
manual therapy techniques (97140). You say that you cannot afford $390. The Plan denied your request. The 
Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray of the lower and sacral spine (72100), the office visit (99203), and 
the manual therapy techniques (97140) provided by a chiropractor on July 13, 2023, to, August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe you are being over charged. 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 25, 2023 with the 
approved and paid D0210. Therefore, we decided that the Plan does not have to pay for panoramic radiographic 
images (D0330) provided on July 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for deluxe frame (V2025), progressive lenses (V2781), 
and vision supplies (V2797) provided on July 13, 2023. 
 
You asked the Plan to reimburse for deluxe frame (V2025), progressive lenses (V2781), and vision supplies 
(V2797). You say that you called before you went to the eye doctor appointment to find out if indeed your 
insurance would cover your complete cost. You also say you were told yes. The Plan denied your request. The 
Plan says the benefit has been exhausted. 
 
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 up to $100 towards the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers a $100 benefit toward the 
purchase and fitting of eyeglasses and pair of lenses. The Plan rules also say you are responsible for any 
amount over the $100 retail price. The record shows this benefit was exhausted with this date of service. Based 
on this information, we decided that the Plan's rules for coverage of deluxe frame (V2025), progressive lenses 
(V2781), and vision supplies (V2797) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for deluxe frame (V2025), progressive lenses (V2781), and vision supplies (V2797) provided on 
July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided by a chiropractor on 
August 9, 2023. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the lumbar-sacral orthosis is covered by 
Medicare. The Plan denied your request. The Plan says that a lumbar-sacral orthosis is not a covered benefit 
when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the lumbar-sacral orthosis provided by a chiropractor on August 9, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 2, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice on this 
date. 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 ambulance services provided on August 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint injection (64495). 
 
You asked the Plan to pre-approve a lumbar facet joint injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 lumbar facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD utilization 
criteria limits the diagnostic medial branch blocks to one or two levels bilaterally. A third level is allowed only 
with documentation of extraordinary circumstances which are not present here. Therefore, a third level is 
considered not medically 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 a lumbar facet joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar facet joint injection (64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for add clasp to existing partial denture (D5660) provided on 
July 10, 2023, to August 1, 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 Plan's 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 adding a clasp to existing partial denture was exhausted on date of service July 10, 
2023, to August 1, 2023. Therefore, we decided that the Plan does not have to pay for adding a clasp to existing 
partial denture (D5660)) provided on July 10, 2023, to August 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for the enrollee.

You asked the Plan to provide coverage for a PET scan. 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 noted that the NCD specifically states that
a PET scan is only covered for cancers that are biopsy-proven or where cancer is strongly suspected based on
other diagnostic testing. Based on the medical records provided, cancer is not strongly suspected.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that PET scans are
covered only when they are medically necessary. Based on the Medical records provided, the enrollee does not
meet the required criteria as there are not biopsy results or diagnostic suspicions for caner in the enrollee.
Therefore, we decided that the Plan does not have to provide coverage for a positron emission tomography
(PET) scan with concurrently acquired computed tomography (CT) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns and pontics (D6750, D6242) provided on 
June 3, 2023, to June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 7, 2023. Therefore, 
we decided that the Plan does not have to pay for retainer crowns and pontics (D6750, D6242) provided on 
June 3, 2023, to June 13, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes J1642, A4221, A4223 and E0776 
provided July 12, 2023, through July 18, 2023. 
 You asked the Plan to pay for the procedure codes J1642, A4221, A4223 and E0776. You say that the services 
were medically necessary and should be covered. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 8, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the procedure codes J1642, 
A4221, A4223 and E0776 provided July 12, 2023, through July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance and filling (D2391, D4910) 
provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for fillings has already been 
exhausted. Additionally, this benefit does not include periodontal maintenance.  
 
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 November 3, 2021 
(D2391). Therefore, we decided that the Plan does not have to pay for periodontal maintenance and filling 
(D2391, D4910) provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring services provided on July 10, 
2023. 
 
You asked the Plan to pay for remote physiologic monitoring services. You say that these services were 
medically necessary. 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 remote physiologic 
monitoring services provided on July 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 26, 
2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for this service. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was brought in by ambulance to the Emergency Department (ED) on  
January 26, 2023 from the Adult Living Facility (ALF) where she resides due to a fall the previous day. The 
ALF would not take her back because of her recurrent falls and deconditioning. The ED workup was 
unremarkable with no acute findings. The enrollees symptoms improved prior to the decision to admit. She 
was discharged to a Skilled Nursing Facility approximately 8 hours after arriving to the hospital. The review 
has determined that the record did show that at the time of the inpatient admission it was reasonable for the 
admitting physician to expect that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights with supporting documentation of the enrollees history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing osseous surgery and bone replacement grafts 
(D4264, D4260, D4263) provided on March 27, 2023. 
 
You asked the Plan to waive the cost-sharing the osseous surgery and bone replacement grafts. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. Additionally, this benefit does not include bone 
replacement grafts. 
 
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. Additionally, this benefit does 
not include bone replacement grafts. 
 
You have been asked to pay a $1,000 deductible and $60 copayment for osseous surgery. This item/service 
falls 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. Additionally, this benefit does not include bone replacement grafts. Therefore, 
we decided that the Plan does not have to waive the cost-sharing osseous surgery and bone replacement grafts 
(D4264, D4260, D4263) provided on March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. 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 lab services provided on 
July 14, 2023.