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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the surgical 
removal of an erupted tooth (D7210) for tooth #29 provided by an out-of-network provider on January 30, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that the services 
were 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. Also, it was verified with the provider 
that they told you that they are not an in-network provider with 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and the surgical removal of an erupted tooth (D7210) for 
tooth #29 provided by an out-of-network provider on January 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you would like the additional trips as you 
go to the doctor every 3 months but you need more non-medical rides as you have already used all of your time 
for the year. You also say that it's unfair and would like for your benefit to be used for more non-medical trips. The Plan denied your request. The Plan says the record shows as of November 3, 2023, you have used or 
scheduled 24 non-health related one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the interim crowns (D2799 x 2) purchased 
on June 15, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items provided are not 
covered under the supplemental dental policy. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
interim crowns (D2799 x 2) purchased on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99241), chiropractic manipulative treatment 
(98941), mechanical traction therapy (97012), hot or cold packs therapy (97010), and electrical stimulation 
(97032) provided by a chiropractor on January 3, 2023, to April 27, 2023. 
 
  You asked the Plan to pay for the office visit (99241), chiropractic manipulative treatment (98941), mechanical 
traction therapy (97012), hot or cold packs therapy (97010), and electrical stimulation (97032). You say that 
the provider is out of network and does not accept insurance. You say that chiropractic visits are part of your 
benefit with your current Health Plan. The Plan denied your request. The Plan says you did not send in an 
itemized statement to be reimbursed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit (99241), chiropractic 
manipulative treatment (98941), mechanical traction therapy (97012), hot or cold packs therapy (97010), and 
electrical stimulation (97032) have been met. Specifically, you have not provided an itemize bill with the actual 
charges. Therefore, we decided that the Plan does not have to pay for the office visit (99241), chiropractic 
manipulative treatment (98941), mechanical traction therapy (97012), hot or cold packs therapy (97010), and 
electrical stimulation (97032) provided by a chiropractor on January 3, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on July 29, 
2021, to, September 30, 2021. 
 
You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says 
the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for chiropractic manipulative treatment was not filed until May 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on 
July 29, 2021, to, September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimbursement for hearing aids (V5298) provided on February 2, 
2023. 
 
You asked the Plan to reimbursement for hearing aids (V5298). You say that after not being satisfied with the 
Plan's product, in early 2023 you were directed to this provider to investigate vendor specific hearing aids. You 
also say that regardless of this provider's relationship to the Plan, you should be eligible for 80% 
reimbursement for Durable Medical Equipment. The Plan denied your request. The Plan says items are to be 
supplied by the Plan hearing. 
 
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 provided from 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 
reimbursement for hearing aids (V5298) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of intra-socket biological dressing (D7922) 
provided on August 9, 2023. 
 
You asked the Plan to pay for placement of intra-socket biological dressing. 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 placement 
of intra-socket biological dressing (D7922) provided on August 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way transportation trips. 
 
You asked the Plan to pre-approve additional one-way transportation trips. You say that you need additional 
transportation trips. The Plan denied your request. The Plan says you have used 24 trips as of August 16, 2023. 
The Plan also says you have exhausted this benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular complete denture (D5120) and maxillary 
partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered benefits under the enrollee's 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular complete denture (D5120) and maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on May 12, 2023. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you provided medical records to support 
payment for this item. 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 shoulder orthosis provided on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics and cardio hereditary genetic testing 
provided on May 15, 2023. 
 
You asked the Plan to pay for the pharmacogenetics and cardio hereditary genetic testing. You say that the 
provided pharmacogenetics and cardio hereditary genetic testing provided was medically necessary. The Plan 
denied your request. The Plan says the enrollee did not meet criteria for the provided pharmacogenetics and 
cardio hereditary genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the pharmacogenetics and cardio hereditary 
genetic testing. Our reviewer says that the enrollee did not meet criteria for the provided pharmacogenetics and 
cardio hereditary genetic testing. Our physician reviewer found in the absence of congenital heart disease, or 
sudden cardiac death or abnormal electrocardiogram (ECG) reflecting Qt interval abnormalities, 
Pharmacogenetic, and hereditary tests are medically nonproductive and unnecessary. 
 
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 pharmacogenetics and cardio hereditary genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the pharmacogenetics and cardio hereditary 
genetic testing provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic retainer crown for tooth number 9 
(D6740) provided on June 1, 2023. 
 
You asked the Plan to pay for this item. 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 item 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 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 the item provided has already been exhausted. Specifically, the Plan's contract states 
that one pontic or retainer crown is covered every five years. On this day, you received two retainer crowns. 
The Plan issued payment for the retainer crown provided for tooth number 7. Therefore, you have exhausted 
the allowable benefit for this dental item. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic retainer crown for tooth number 9 (D6740) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontal maintenance follow-up appointment 
(D4910), and core buildup, including any pins when required (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot get the crown without this post 
and you need the periodontal maintenance. The Plan denied your request. The Plan says these services are not 
covered in your dental benefit. 
 
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 pre-approve a 
periodontal maintenance follow-up appointment (D4910), and core buildup, including any pins when required 
(D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that your doctor informed you 
about the nerve block injection for both knees. You would like to try it in your right knee due to it hurting 
every day, some days are worse than others. You state your activities are limited due to the pain. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knees. There 
is insufficient literature to support the safety and efficacy, as defined by Medicare rules. The record provided does not establish the medical necessity and reasonableness of the requested service. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 provided on April 13, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 33214 
provided on February 13, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 provided on 
April 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
19, 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 June 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an SNF stay from June 16, 2023, to June 22, 2023.  
 
You asked the Plan to pay for SNF stay.. You say that a SNF stay was medically necessary. The Plan denied 
your request. The Plan says a SNF stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 31, 2023, to 
June 22, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for an SNF stay from June 16, 2023, to June 22, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code(s) 93005, 96360, 96361, A4556, and A4649
billed for date of service September 23, 2022.

You asked the Plan to pay for procedure code(s) G0378, 70496, 70498, and 70450. You say that the claim is
billed correctly and should be paid. The Plan denied your request. The Plan says this code is included in the
facility payment and is not separately payable. Maximus partially overturned the Plan's denial for lack of
information. The Plan requested a reopening and confirmed the procedure codes Maximus overturned have
been covered and paid by the Plan.

The Plan must follow Medicare rules. Medicare rules say that the TC of radiology and other diagnostic services
furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the
hospital. The rules also say that if an item or service is covered as incident to a physician service and is
provided on the same day as a physician service, payment for it is bundled into the payment for the physician
service to which it is incident.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services described by procedure code(s) 93005, 96360, 96361, A4556, and A4649 have not
been met. Procedure codes 93005, 96360, and 96361 are technical components and are not payable in the
facility setting. Codes A4556 and A4649 have a status indicator of P and are not separately payable. Therefore,
we decided that the Plan does not have to pay for procedure code(s) 93005, 96360, 96361, A4556, and A4649
billed for date of service September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin lesion removal provided by an in-
network provider on June 5, 2023. 
 
You asked the Plan to waive the copayment for the skin lesion removal. You say that you do not agree with the 
copayment. 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 $330 
copayment for all other in-network outpatient services not provided in an ambulatory surgical center. 
 
You have been asked to pay a $330 copayment for the skin lesion removal. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 the skin lesion removal provided 
by an in-network provider on June 5, 2023.