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

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
bitewing x-ray, single radiographic image (D0270), porcelain/ceramic crown (D2740), core buildup, including 
any pins when required (D2950), periodic oral evaluation (D0120), dental cleaning (D1110), and the topical 
application of fluoride varnish (D1206) provided from February 28, 2023, through April 6, 2023.  
 
You asked the Plan to pay for these dental items/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 items/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 items/services provided was previously exhausted. Specifically, the annual 
maximum allowable dental benefit is $1,500. The Plan issued payments in the total amount of $1,500 which 
included ($46 + $50 + $941 + $463) for dental items/services provided in the 2023 calendar year. Therefore, 
you have exhausted the allowable benefit for the items/services provided in this case. Therefore, we decided 
that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), bitewing x-ray, 
single radiographic image (D0270), porcelain/ceramic crown (D2740), core buildup, including any pins when 
required (D2950), periodic oral evaluation (D0120), dental cleaning (D1110), and the topical application of 
fluoride varnish (D1206) provided from February 28, 2023, through April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 21, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were referred to the oral surgeon. 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 the Plan paid for a limited oral evaluation on August 14, 2023; therefore, your benefit for the requested 
item or service was exhausted on the date of service of August 14, 2023. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140) provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on July 10, 
2023. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that the portable rental that you have 
had for years is supposed to go up to four liters, but it only goes to 3 and therefore is no longer any use to you. 
The Plan denied your request. The Plan says the purchased portable oxygen concentrator is not a covered 
benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
concentrator purchased on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and related services (68761, 83861,
92285) provided to the enrollee on September 27, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that this was medically necessary. The Plan denied your
request. The Plan says that this was not authorized. Maximus overturned the Plan's denial because of a lack of
information. The Plan requested a reopening and submitted the 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 office visit (99214) and related services
(68761, 83861, 92285) provided to the enrollee on September 27, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine
transportation.

You asked the Plan to pre-approve an exception to supplemental benefits. You say that you are unable to drive
and have no family or friends to drive you. The Plan denied your request. The Plan says your benefit only
allows 50 miles, and this request exceeds your benefit limit. Maximus overturned the Plan's denial. The Plan
requested a reopening and stated that this request exceeds the benefit limit. The Plan is correct in this case.

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 Plan's coverage rules apply in this
case. The Plan covers routine transportation up to 50 miles of driving distance. While plans may offer
supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to
supplemental benefits and your request is for transport over the 50-mile limit. Therefore, we decided that the
Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Positive Air Pressure (CPAP) machine 
(E0601) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the CPAP machine. You say that this item is medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a Continuous 
Positive Air Pressure (CPAP) machine (E0601) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation (D0120) and 
the periodontal maintenance (D4910) provided by an out-of-network provider on July 20, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you went to your regular 
dentist for a cleaning, and you were charged a 20% copay and before the provider was in-network. 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 preventive and comprehensive dental services when provided by an out-of-network provider.  
 
  The total allowed amount for the periodic oral evaluation (D0120) was $62 and the coinsurance amount was 
$12.40 ($62 allowed x 20% coinsurance). The total allowed amount for the periodontal maintenance (D4910) 
was $125 and the coinsurance amount was $25 ($125 allowed x 20% coinsurance). 
 
You have been asked to pay a 20% 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 the periodic oral 
evaluation (D0120) and the periodontal maintenance (D4910) provided by an out-of-network provider on July 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) provided on August 3, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. The Plan denied your request. The Plan 
says dental code D0350 is not listed as covered in the Patient Charge Schedule guide. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) provided on August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs (K0108). 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the wheelchair repairs are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. The repairs are requested for a second power wheelchair 
serves the same purpose as the currently used power wheelchair. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair repairs (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2335) for tooth #8 and to 
pay for a resin-based composite (D2335) for tooth #9 and #10 provided on November 1, 2022, and November 
14, 2022 . 
 
You asked the Plan to pay more for the dental services. You say that you never received anything for the 
services until the end of January of 2023 and you told the provider to make sure to only do what the Plan 
covers. 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 $279.54 for dental services on September 27, 2022. On October 6, 2022, the Plan paid 
$944.76 for dental services. On October 27, 2022, the Plan paid $643.28 for dental services. On November 1, 
2022, the Plan paid $632.42 for dental services. For the year of 2022 the Plan paid $2,500 ($279.54 paid + 
$944.76 paid + $643.28 paid + $632.42 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2022 was exhausted on the date of service of November 1, 2022. Therefore, we decided 
that the Plan does not have to pay more for a resin-based composite (D2335) for tooth #8 and to pay for a resin-
based composite (D2335) for tooth #9 and #10 provided on November 1, 2022, and November 14, 2022 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to crown (D6058) for tooth #12 provided on August 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that the Plan 
would cover the dental services. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because implant and all related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a custom 
fabricated abutment (D6057) and an abutment supported to crown (D6058) for tooth #12 provided on August 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953), guided tissue regeneration 
(D4266) and surgical placement of implant body (D6010) provided on August 3, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 a bone 
replacement graft (D7953), guided tissue regeneration (D4266) and surgical placement of implant body (D6010) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 2, 2023, to June 16, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on June 2, 2023, to 
June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), 
pontic (D6240), and retainer crown (D6750) provided on August 22, 2023. 
 
You asked the Plan to pay more for the pontic and retainer crown. You say that you do not agree with the cost 
shares and how your claims were denied for services you thought were covered.  The Plan denied your request. 
The Plan says the cost sharing for these services was charged correctly. 
 
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 contract clearly states that you 
must pay 50% coinsurance for each major service. The record shows that you have been correctly charged 50% 
coinsurance for both the pontic (D6240) and retainer crown (D6750), and your total share of $765.00 is correct. 
Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation 
(D0140), pontic (D6240), and retainer crown (D6750) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for detailed oral evaluation (D0160) and panoramic radiographic 
image (D0330) provided on August 16, 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 panoramic radiographic image has already been exhausted. A 
detailed oral evaluation 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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service April 5, 2023. Therefore, we decided that the Plan does not have to pay for detailed oral evaluation (D0160) and panoramic 
radiographic image (D0330) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the panoramic 
radiographic image (D0330), and a cleaning (D1110) provided September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that your second cleaning should be covered. The 
Plan denied your request. The Plan says your annual dental 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 $160.34 for dental services on March 6, 2023. On March 9, 2023, the Plan paid $209.67 
for dental services. On April 11, 2023, the Plan paid $129.99 for dental services. For the year of 2023 the Plan 
paid $500 ($160.34 paid + $209.67 paid + $129.99 paid) for dental services; therefore, your annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of April 11, 2023. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the panoramic radiographic 
image (D0330), and a cleaning (D1110) provided September 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site for 
tooth# 14 (D7953) provided on August 3, 2023. 
 
You asked the Plan to pay for this dental service. 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 service 
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 service provided was exhausted on date of service August 3, 2023. Specifically, the 
Plans contract states that the annual maximum dental benefit is $1,500. The Plan issued payments in the total 
amount of $1,500 ($1,015.48 + 174.52 + $189 + $121) for dental services provided in the 2023 calendar year. 
Therefore, you have exhausted the allowable benefit for the service provided in this case. Therefore, we 
decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site for 
tooth# 14 (D7953) provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and COVID test provided on December 24,
2021, by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that this should be covered. The Plan denied your
request. The Plan says that coverage of out-of-network services requires authorization. Maximus overturned the
Plan's denial because of a lack of information. The Plan requested a reopening and provided the 2021 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 office visit and COVID test provided on
December 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 provided from January 9, 
2023, to January 11, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J43.2 has an Excludes1 note in relation to J44.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for procedure codes 99223 and 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99223 and 99233 provided from January 9, 2023, to January 11, 2023.