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

 
We decided that the Plan does not have to pay for the pontics-porcelain fused to high noble metal (D6240 x 2) 
and the retainer crowns-porcelain fused to high noble metal (D6750 x 2) provided on June 6, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your dental benefit 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 items provided was exhausted as of October 17, 2023. Specifically, the Plan's 
maximum annual dental benefit is $2,000. The Plan previously issued payment for the total amount of  
$2,000 ($246 +$480+$188+$68+$1,018) for dental services provided in the 2023 calendar year. Therefore, you 
have exhausted the allowable dental benefit for this calendar year. Therefore, we decided that the Plan does not 
have to pay for the pontics-porcelain fused to high noble metal (D6240 x 2) and the retainer crowns-porcelain 
fused to high noble metal (D6750 x 2) provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on July 11, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physicians services 
provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radio frequency ablation (RFA) 
(64624). 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the services are experimental for knee pain treatment. 
 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 RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radio frequency ablation (RFA) (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete intraoral series of radiographic images (D0210) 
provided August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an appointment with your regular 
dentist, but was informed they were no longer in-network, so you cancelled the appointment. You also say that 
when you went to the new dentist, they informed you they would need to take x-rays as you were a new patient. 
You also say there was nothing mentioned about charged. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete intraoral series of radiographic images 
(D0210) provided August 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an additional outer surface protective covering
(L5962) for the enrollee.

You asked the Plan to provide coverage for this accessory. The Plan denied your request. The Plan says the
records provided do not support the need for this additional covering for the enrollee.

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 standard cover that comes included with the approved below knee
prosthetic meets the enrollee's needs. There is no indication that the enrollee is exposed to harsh elements on a
continual basis that would require the requested additional cover.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the requested
additional covering is approved for an enrollee who has special needs for protection against unusually harsh
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of
protection that is standard. They are not for cosmetic or convenience reasons, or for everyday usage in a typical
environment. We looked at the file and Medicare rules. There is insufficient information in the record to show
the enrollee has special environmental needs that requires the additional covering. Therefore, we decided that
the Plan does not have to provide coverage for an additional outer surface protective covering (L5962) for the
enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the colonoscopy provided on May 22, 
2023. 
 
You asked the Plan to waive the coinsurance for the colonoscopy. You say that this service should be fully 
covered. 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 20% 
coinsurance for Medicare-covered diagnostic tests.  
 
You have been asked to pay $160.80, which is 20% coinsurance of the allowed amount for the colonoscopy 
($804 allowed amount x 20% = $160.80). This item/service falls within the outpatient diagnostic tests and 
therapeutic services and supplies 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 colonoscopy provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 13, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 13, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on July 13, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit provided on April 28, 2022. 
 You asked the Plan to pay for the ER visit. You say that the services were medically necessary. 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 an emergency room (ER) visit provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on May 04, 2023. 
 
You asked the Plan to pay for a telehealth visit. You say that the enrollee was in a nursing home at the time the 
service was rendered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth visit 
provided on May 04, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head. 
 
You asked the Plan to pay for the CT scan. You say that the claim has been corrected and ask for the payment 
to be reconsidered. The Plan denied your request. The Plan says the corrected claim was not received within 
the time limit. 
 
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 the CT scan was not filed until July 22, 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 the computed tomography (CT) scan of the head.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on June 1, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the claim has been improperly denied. The Plan denied your request. The Plan says without transport there are 
no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup (D2950, D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider 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. 
 
 
  You are requesting 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 pre-approve a crown 
and core buildup (D2950, D2740).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you have submitted the billing and medical 
records and ask that the plan reconsider payment. The Plan denied your request. The Plan says the time limit 
for filing has passed. 
 
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 the ambulance services was not filed until July 11, 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 the ambulance services provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220) and the resin-
based composite (D2392) for tooth #19 on July 12, 2023, and July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have $1,500 annual limit you would like the 
Plan to cover the dental services. The Plan denied your request. The Plan says your benefit for the intraoral 
radiographic image has already been exhausted. Also, the resin-based composite 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, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) on January 4, 2023; therefore, your benefit for 
the intraoral radiographic image was exhausted on the date of service of January 4, 2023. The resin-based 
composite is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for the intraoral radiographic images (D0220) and the resin-based composite (D2392) for tooth #19 on July 
12, 2023, and July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump 
(NPWT) and supplies for month 5 (E2402, A6550).  

You asked the Plan to pre-approve a NPWT and supplies for month 5. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a NPWT pump and supplies is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a NPWT and supplies for month 5. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has been 
treated with NPWT for at least 4 months. The request for a 5th month is not medically necessary as per the 
guideline recommendations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a NPWT and supplies for month 5 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump (NPWT) and 
supplies for month 5 (E2402, A6550).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on July 
31, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that this service was the 
continuation of services rendered in June 2022 on both eyes for cataract surgery. The Plan denied your request. 
The Plan says refractive services are not covered under your medical benefit plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that an eye refraction is only covered when it is 
part of a routine eye examination. The record shows this is a medical eye examination, not routine. Based on 
this information, we decided that the Plan's rules for coverage of a determination of refractive state (92015) 
have not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive 
state (92015) provided on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition requires an 
LTACH admission. The Plan denied your request. The Plan says the enrollee can continue receiving care at the 
current facility until stable enough for discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 31, 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 $3,000 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 $3,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the intraoral-periapical additional radiographic image (D0230) provided on June 30, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these 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 services provided are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic image 
(D0220) and the intraoral-periapical additional radiographic image (D0230) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #12 and #13 provided on 
July 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you see that crowns are covered at 70% 
coinsurance, and you do not see anything about core buildup not being covered. The Plan denied your request. 
The Plan says the denial of payment for these services is correct because core buildup is not covered by the 
Plan. Also, it was verified prior to the date of service you were told the proper dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #12 and #13 provided on July 27, 2023.