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

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210) for tooth #31 
provided by an out-of-network provider on October 31, 2022. 
 
You asked the Plan to pay for the dental service. You say that the oral surgeon demanded full payment before 
they would proceed with the dental service. The Plan denied your request. The Plan says the dental service was 
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 service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is 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 surgical removal of erupted tooth (D7210) for tooth #31 provided by an out-of-network provider on 
October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of benign lesion (D7410) provided on June 19, 
2023. 
 You asked the Plan to pay for the dental services. You say that you would like the Plan to process the claim and 
to reimburse you. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the excision of benign lesion is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
excision of benign lesion (D7410) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns - porcelain fused to high 
noble alloys (D6066), prefabricated abutments  includes modification and placement (D6056), and surgical 
placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these are 
not covered services of your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
supported crowns - porcelain fused to high noble alloys (D6066), prefabricated abutments  includes 
modification and placement (D6056), and surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on June 
6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider took x-rays without telling you 
anything and they did not tell you that you had to pay for them. 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 an intraoral radiographic image (D0230) on June 6, 2023; therefore, your benefit for 
the requested items or services was exhausted on the date of service of June 6, 2023. Therefore, we decided 
that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 3, 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 $1,500 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- complete series of radiographic images (D0210) 
provided on June 10, 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 May 10, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral- complete series of radiographic images (D0210) 
provided on June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and deductible for the periodontal scaling and 
root planing (D4341) on all 4 quadrants provided on December 15, 2022. 
 
You asked the Plan to waive the coinsurance and deductible for the dental services. You say that according to 
your treatment plan the Plan should cover the dental services. 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 20% 
coinsurance for the periodontal scaling and root planing when received in-network after the $50 deductible has 
been met.  
 
The total allowed amount for 1 periodontal scaling and root planing was $186 with a $50 deductible leaving a 
balance of $136. The total coinsurance amount was $27.20 ($136 balance x 20% coinsurance). The total 
allowed amount for each of the other 3 periodontal scaling and root planing was $186 and a coinsurance 
amount for each 1 of $37.20 ($186 allowed x 20% coinsurance). The total cost share amount for all 4 of the 
periodontal scaling and root planing was $188.80 ($50 deductible + $27.20 coinsurance + $37.20 coinsurance + 
$37.20 coinsurance + $37.20 coinsurance). 
 
You have been asked to pay a 20% coinsurance and a $50 deductible for the dental services. This item/service 
falls within the supplemental dental benefits 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 coinsurance and 
deductible for the periodontal scaling and root planing (D4341) on all 4 quadrants provided on December 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says an appropriate 
modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that EM services that are unrelated to the surgical 
procedure should be billed with modifier -24, and unrelated surgical procedures should be billed with modifier 
-79.  We looked at the file and Medicare rules. Code 99233 was provided within the global surgery period for code 
33274 provided on June 30, 2022. We find that although the service be unrelated to the surgical procedure, 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 99233 billed for date of service 
July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed, fixed height, with any type side rails, with 
mattress (E0250), air pressure mattress (E0186), DME delivery, set up, and/or dispensing service (A9901), and 
sales tax (S9999), purchased from a non-participating provider who is not certified with Medicare, on 
November 20, 2022. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the items should be 
covered. The Plan denied your request. The Plan says these were purchased through a provider that is not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital bed, fixed height, with any 
type side rails, with mattress (E0250), air pressure mattress (E0186), DME delivery, set up, and/or dispensing service (A9901), and sales tax (S9999), purchased from a non-participating provider who is not certified with 
Medicare, on November 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a raised toilet seat (E0244).  
 
You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that the requested items are 
at the utmost importance for your daily living and well-being. 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 and raised toilet seats are not 
covered because they are not primarily medical in nature. 
 
While a shower chair and a raised toilet seat 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 
(E0240) and a raised toilet seat (E0244).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branches injections. 
 
You asked the Plan to pre-approve genicular nerve branches injections. You say that the enrollee has done 
physical therapy many times and takes medication to help with the knee pain but feels this would be the most 
beneficial. 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 branches injections. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered experimental investigational at this time. It is the 
subject of ongoing clinical trials. Therefore, the request is deemed 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 genicular nerve branches injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular nerve branches injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test guides the appropriate treatment choice. 
The Plan denied your request. The Plan says repeat testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records show that the same test was approved by the Plan for a 
different date of service. Repeat NGS testing is not covered using the same cancer genetic content. 
Additionally, the panel test was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the panel testing billed for date of service July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for gym membership rendered from January 1, 2023, to 
June 30, 2023. 
 
You asked the Plan to reimburse for gym membership. You say that you were not aware of the 2023 change to 
Silver Sneakers, therefore you are appealing the denial of payment. The Plan denied your request. The Plan 
says the Plan is no longer issuing direct-to-member fitness reimbursement checks based on submission year. 
The Plan also says that the Plan's fitness benefit coverage now falls under the Flex Card benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when you go through the Silver Sneakers Flex card. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the Plan no longer offers 
reimbursement, but uses the Silver Sneakers membership. Therefore, we decided that the Plan does not have to 
reimburse for gym membership rendered from January 1, 2023, to June 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing services provided by an out-of-network 
(OON) provider on June 12, 2023. 
 
You asked the Plan to pay for the diagnostic testing services provided OON. You say that the medical records 
support that the services provided were medically necessary and provided OON for continuity of care reasons. 
The Plan denied your request. The Plan says there is no referral on file and no request for authorization. The 
Plan says that the services were not urgent or emergent. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 diagnostic testing services provided 
OON. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer 
found there is no evidence that the enrollee was receiving any active treatment and/or medical management of 
their condition that made it medically necessary to continue care with the OON provider. There was nothing 
unique about the enrollee's condition that would have made it medically necessary to continue care OON. The 
Plan has shown that they had in-network specialists who have the qualifications and expertise necessary to 
meet the current medical Standards of Care required for treatment of the enrollee's condition. The enrollee's 
medical management and/or follow-up care could have been safely transitioned to a network specialist at the 
time the service in dispute was provided. 
 
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 diagnostic testing services provided OON have not been met. Therefore, we 
decided that the Plan does not have to pay for diagnostic testing services provided by an out-of-network (OON) 
provider on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says 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 medical records show the enrollee's ability to participate in intensive
therapy was described as limited by the hospital physical therapist, given their limited activity tolerance, pain
and increased fatigue.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
medical records do not show the enrollee had the ability to participate in at least three hours of therapy per day
at least five days per week. Medicare rules. Based on this information, we decided that Medicare rules for
coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage
for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement motor. 
 
You asked the Plan to pre-approve a replacement motor. You say that you need the scooter because of your 
conditions which are on file already. You also say that several months into receiving this scooter, the motor has 
stopped working, and you need this to get around. The Plan denied your request. The Plan says this request is 
not a covered benefit as the scooter was previously denied. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will not pay for the repairs of 
previously denied equipment.  
 
 
 
 We looked at the file and Medicare rules. Specifically, the documentation shows that on March 23, 2023, the 
Plan denied your request for the purchase of a heavy-duty power scooter, which you are now requesting the 
motor to be replaced on. Since the scooter was previously denied, the requested replacement motor cannot be 
covered. Based on this information, we decided that Medicare rules for coverage of a replacement motor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement motor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 28. 
 
You asked the Plan to pre-approve the dental services. You say that you did not know crowns could break. 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 28, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic card (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that your front nerve is exposed, and the tooth 
not being removed is creating discrepancies with your mental health. 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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a porcelain or ceramic card (D2740).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve a Syn-One test. 
 
You asked the Plan to pre-approve the requested testing. You say that the test would be helpful in the treatment 
of your symptoms. The Plan denied your request. The Plan says that the testing is not covered by Medicare or 
approved by the Food and Drug Administration (FDA). 
 
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. 
 
We looked at the file and the rules. The Plan has not provided a citation that indicates that a lab test must be 
FDA approved to be covered. There is not a specific Medicare ruling that states the specific requested testing 
must be FDA approved for coverage. Medical records were requested, however, the Plan declined the 
opportunity to obtain records. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pre-
approve a Syn-One test.  
 
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.