Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided to the enrollee from
January 17, 2023, to January 30, 2023, by an out-of-network (OON) provider.

You asked the Plan to pay for the physical therapy services. You say that this was medically necessary and
should be covered. The Plan denied your request. The Plan says that there was no preauthorization by a
primary care provider for an out-of-network (OON) provider or facility, and this was not an emergency.

Maximus overturned the Plan's denial based on a lack of information. The Plan requested a reopening and
provided the 2023 EOC.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided to the
enrollee from January 17, 2023, to January 30, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 19, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on August 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral - periapical first radiographic image 
(D0220) provided on August 4, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you discovered that the provider charged 
you $400 for the x-rays, and that is way too much for you. You also say that you want them to reduce the 
amount of the bill and reprimand them for treating disabled patients in this manner. The Plan denied your 
request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when 
your services are received from an out-of-network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the intraoral - periapical first radiographic 
image (D0220) provided on August 4, 2023.  
 
Your complaint about the treatment you received from the provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre 2 sensors provided on July 7, 2023. 
 
You asked the Plan to pay for the FreeStyle Libre 2 sensors. You say that you have submitted proof of delivery 
along with other supporting documentation but the claim keeps denying for missing information. The Plan 
denied your request. The Plan says this service is not supported by the documentation submitted and is not 
eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that that the suppliers record must have a description 
of the item(s) being delivered. 
 
We looked at the file and Medicare rules. The record does not contain a valid a description of the item(s) being 
delivered. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 2 
sensors have not been met. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre 2 
sensors provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on August 
30, 2023. 
 
You asked the Plan to pay for the therapeutic parenteral drug. You say that you were supposed to receive these 
services from a different dentist. You also say that you were not aware that the dentist that performed these services was not in-network. The Plan denied your request. The Plan says therapeutic parenteral drug is not 
listed as a covered 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 service at issue in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
therapeutic parenteral drug (D9610) provided on August 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 20680 billed to the enrollee for date of
service January 6, 2023.

You asked the Plan to pay for code 20680. The Plan denied your request. The Plan says the Medicare billing
criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct billing criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, based on the procedure reported, code 20680 cannot be separately billed
per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for procedure code 20680
billed to the enrollee for date of service January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for upgraded electronics (E22313, E2311, and
E2377) for the enrollee.

You asked the Plan to provide coverage for upgraded electronics (E22313, E2311, and E2377). You say that at
the time of the appeal, the requested upgraded electronics were medically necessary. The Plan denied your
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the
medical records show the enrollee has more than adequate upper extremity strength to operate the standard
switches and does not require a joystick.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The available clinical documentation in the case file
does not support that the requested expandable controller, harness, and electronic connection were medically
reasonable and necessary for the enrollee in this case. The notes do not show the medical necessity of
controlling the power options through a joystick. Therefore, we decided that the Plan does not have to provide
coverage for upgraded electronics (E22313, E2311, and E2377) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
April 20, 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 hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 22, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on September 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a panoramic radiographic image (D0330) 
and a consultation (D9310) provided by an oral surgeon on August 29, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered because the Plan referred you to the dentist. 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 an 80% 
coinsurance for specialist's usual and customary fee per procedure when receiving specialty services.  
 The total amount for the panoramic radiographic image (D0330) was $110 with a coinsurance amount of $88 
($110 total x 80% coinsurance). The total amount for the consultation (D9310) was $190 with a coinsurance 
amount of $152 ($190 total x 80% coinsurance). 
 
You have been asked to pay an 80% coinsurance for the dental services. 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. Therefore, we decided that the Plan does not have to waive the coinsurance for a panoramic radiographic 
image (D0330) and a consultation (D9310) provided by an oral surgeon on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hard night guard (D9940), and full mouth debridement to 
enable a comprehensive periodontal evaluation (D4355) provided on August 21 2023. 
 
You asked the Plan to pay for the dental services. You say that you have to tell the dental providers what 
insurance you have. You also say that the booklets you receive from the plan are misleading pertaining to the 
plans name. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the hard night guard (D9940), and full mouth debridement to enable a comprehensive periodontal 
evaluation (D4355) provided on August 21 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam computed tomography (CT) image capture 
with field of view of one full lower dental arch (D0381), interpretation of a diagnostic image by a practitioner 
not associated with the capture of the image, including report (D0391), and the surgical placement of an 
implant body: endosteal implants (D6010 x 2).  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve cone beam 
computed tomography (CT) image capture with field of view of one full lower dental arch (D0381), 
interpretation of a diagnostic image by a practitioner not associated with the capture of the image, including 
report (D0391), and the surgical placement of an implant body: endosteal implants (D6010 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the removal of residual tooth root (D7250) for tooth #4 
provided on October 2, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you are appealing the denied amount for 
the dental service. The Plan denied your request. The Plan says your annual dental maximum benefit for the 
year 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 $58 for dental services on January 25, 2023. On February 21, 2023, the Plan paid $3,079 
for dental services. On May 23, 2023, the Plan paid $533 for dental services. On Jun 21, 2023, the Plan paid 
$58 for dental services. On August 10, 2023, the Plan paid $65 for dental services. On August 14, 2023, the 
Plan paid $85 for dental services. On August 30, 2023, the Plan paid $63 for dental services. On October 2, 
2023, the Plan paid $59 for dental services. For the year of 2023 the Plan paid $4,000 ($58 paid + $3,079 paid 
+ $533 paid + $58 paid + $65 paid + $85 paid + $63 paid + $59 paid) for dental services; therefore, your 
annual dental maximum benefit for the year of 2023 was exhausted on the date of service of October 2, 2023. 
Therefore, we decided that the Plan does not have to pay more for the removal of residual tooth root (D7250) 
for tooth #4 provided on October 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on September 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services were for a 6-month cleaning and it 
should be covered under preventative care. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year 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 $1,000 for dental services on May 16, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of May 16, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral radiographic image 
(D0220) provided on September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prolotherapy. 
 
You asked the Plan to pre-approve prolotherapy. You say that the requested procedure is medically necessary. 
The Plan denied your request. The Plan says the procedure does not meet the criteria necessary for approval. 
 
The Plan must follow Medicare rules. Medicare rules say the procedure requested is not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The rules say prolotherapy has not been verified by scientifically 
controlled studies and is not reasonable and necessary. Based on this information, we decided that Medicare 
rules for coverage of prolotherapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve prolotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
September 9, 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 these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on September 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified adjunctive procedures (D9999 x 2), bone 
replacement graft for ridge preservation-per site (D7953), collection and application of an autologous blood 
concentrate product (D7921), and the surgical placement of an implant body: endosteal implant (D6010) 
provided on October 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 dental 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 October 4, 2023. Specifically, 
the contract states that the Plan reimburses up to $2,100 every year for non-Medicare covered preventive dental 
services and non-Medicare covered comprehensive dental services combined. The record shows that the Plan 
has issued payments in the total amount of $2,100 ($540 + $250 + 185 + $1,125) for dental services provided 
in the 2023 calendar year. Therefore, you have exhausted the allowable benefit for the services provided in this 
case. Therefore, we decided that the Plan does not have to pay for the unspecified adjunctive procedures 
(D9999 x 2), bone replacement graft for ridge preservation-per site (D7953), collection and application of an 
autologous blood concentrate product (D7921), and the surgical placement of an implant body: endosteal 
implant (D6010) provided on October 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), and endosteal implant (D6010) 
provided on June 2, 2023. 
 
You asked the Plan to pay for the extraction and endosteal implant. You say that you need this implant for a 
sense of peace when you open your mouth. You say that you needed to have your tooth removed as it was 
infected. You also say that you feel this should be covered. The Plan denied your request. The Plan says the 
maximum allowable for dental services was reached while processing this claim. The Plan also says that after 
the annual maximum is exhausted, any remaining charges are the enrollee's responsibility. 
 
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 the annual maximum dental allowance has been exhausted in the processing of the claim for the date of 
service in this case. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), and 
endosteal implant (D6010) provided on June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exams provided by a chiropractor on July 21, 2023. 
 
You asked the Plan to pay for the x-ray exams. You say that the x-rays were required prior to treatment. 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 exams provided by a chiropractor on July 21, 2023.