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

 
We decided that the Plan does not have to pay for pre-diagnostic test (D0431) provided on August 2, 2023. 
 
You asked the Plan to pay for pre-diagnostic test. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pre-
diagnostic test (D0431) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
July 10, 2023, July 18, 2023, August 9, 2023, and September 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were misled about your cleanings and were 
told you would not be charged. The Plan denied your request. The Plan says the denial of payment for these 
services is correct because the periodontal scaling and root planing is not covered by the Plan. Also, it was 
verified that you were advised on what dental services were covered. 
 
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 
periodontal scaling and root planing (D4341) provided on July 10, 2023, July 18, 2023, August 9, 2023, and 
September 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care to recover from surgeries. The 
Plan denied your request. The Plan says your medical condition does not require IRF services, and care can be 
provided in another setting.  
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified restorative procedure (D2999) provided on 
July 17, 2023. 
 
You asked the Plan to pay for D2999. You say that your tooth is causing discomfort. The Plan denied your 
request. The Plan says the denied dental service is not 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified restorative procedure (D2999) provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this is experimental and investigational 
because the effectiveness and improvement of health outcomes for treatment of knee osteoarthritis with these 
approaches has not been established. 
 
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 radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. The review has determined that the requested genicular nerve radiofrequency ablation is not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
May 27, 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 (V5261) purchased on May 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oxygen concentrator purchased on August 19, 
2022. 
 
You asked the Plan to reimburse you for the oxygen concentrator you purchased. You say that you did not 
realize you needed to use a different provider. The Plan denied your request. The Plan says you obtained the 
item from a provider who 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 reimburse you for the oxygen concentrator 
purchased on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 19,
2022.

You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not
separately payable. Maximus partially overturned the Plan's denial. The Plan requested a reopening and
confirmed they provided payment for procedure codes 01925 and 36620.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate procedure code.

We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 99100 billed for date of service April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical placement of implant body (D6010) 
provided on June 8, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the provider agreed to do the dental 
implants with the remaining balance after your cleaning. 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 $152 for dental services on May 3, 2023. On June 8, 2023, the Plan paid $4,348 for dental 
services. For the year of 2023 the Plan paid $4,500 ($152 paid + $4,348 paid) for dental services; therefore, 
your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of June 8, 2023. 
Therefore, we decided that the Plan does not have to pay more for the surgical placement of implant body 
(D6010) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the chiropractic manipulative 
treatment (98941) provided on July 19, 2023, to July 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit (99203) and the chiropractic manipulative treatment (98941). You 
say that you had experienced a similar severe lower back pain about 12 years ago. You say that you found 
relief with a course of medication and gentle chiropractic adjustments. The Plan denied your request. The Plan 
says the office visit (99203) and the chiropractic manipulative treatment (98941) are available in network. 
 
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 (99203) and the chiropractic 
manipulative treatment (98941) provided on July 19, 2023, to July 28, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom tilt in space wheelchair with custom seating 
(E0951, E0953, E0955, E0956, E0961, E0971, E0973, E0990, E1002, E1028, E1161, E2201, E2204, E2211, 
E2213, E2231, E2609, E2617, K0040, K0108). 
 
You asked the Plan to pre-approve a custom tilt in space wheelchair with custom seating. You say that the 
items are necessary. The Plan denied your request. The Plan says the enrollee resides in a long-term care 
facility. Therefore, the items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a custom tilt in space wheelchair with custom seating is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a custom tilt in space wheelchair 
with custom seating (E0951, E0953, E0955, E0956, E0961, E0971, E0973, E0990, E1002, E1028, E1161, 
E2201, E2204, E2211, E2213, E2231, E2609, E2617, K0040, K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osteopathic manipulative treatment (OMT) (9-10 body 
regions) provided on June 22, 2023. 
 
You asked the Plan to pay for osteopathic manipulative treatment (OMT) (9-10 body regions). You say that 
procedure code 98929 is appropriate based on the services provided. The Plan denied your request. The Plan 
says the medical record does not support the performance of osteopathic manipulative treatment to 9-10 body 
regions. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 98929 is osteopathic manipulative treatment (OMT); 9-
10 body regions involved. 
 
We asked our coder 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 osteopathic manipulative treatment (OMT) (9-10 body 
regions). Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our reviewer found the record does not contain evidence that osteopathic manipulative treatment was 
performed on 9-10 body areas. Therefore, the documentation does not support that 98929 was performed as 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteopathic manipulative treatment (OMT) (9-10 body regions) have not been 
met. Therefore, we decided that the Plan does not have to pay for osteopathic manipulative treatment (OMT) 
(9-10 body regions) provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-comprehensive series of radiographic images 
(D0210), 2D oral/facial photographic image obtained intraorally or extraorally (D0350 x4) and a panoramic 
radiographic image (D0330) provided on August 2, 2023. 
 
You asked the Plan to pay for the dental x-rays. You say that payment for the imaging studies was denied. You 
say you are requesting reevaluation of coverage. The Plan denied your request. The Plan says these services are 
not covered expenses under 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 an 
intraoral-comprehensive series of radiographic images (D0210), 2D oral/facial photographic image obtained 
intraorally or extraorally (D0350 x4) and a panoramic radiographic image (D0330) provided on August 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 14. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says 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 dates of service February 24, 2023, and 
September 19, 2023. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for 
tooth number 14.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. 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 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 provided do not show that at the time of the appeal, the enrollee required daily skilled
nursing and daily skilled rehabilitation at an IRF level of care. Medicare rules for coverage of IRF care have
not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation
facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a surgical access to an implant body (D6011) and abutment 
supported crown (D6058) 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial to resolve 
certain contradictory filing instructions. The Plan denied your request. The Plan says that your benefit for the 
requested item or service has already been exhausted. 
 
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.  
 
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 does not say in clear and accurate terms 
the benefit limitations for the requested procedures. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. There are no limitations for these procedures in the EOC and the dental rider provides additional 
information in an ambiguous language. Therefore, we decided that the Plan has to pre-approve a surgical 
access to an implant body (D6011) and abutment supported crown (D6058)  
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation with a medicinal agent (D4921) and 
localized delivery of antimicrobial agents (D4381) provided on October 18, 2022. 
 
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 this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation with a medicinal agent (D4921) and localized delivery of antimicrobial agents (D4381) provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia each subsequent 15-minute 
increment (D9223 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need hour of sedation because you 
take an anticoagulant. 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 on authorization 
A0231004148205. Therefore, we decided that the Plan does not have to pre-approve general anesthesia each 
subsequent 15-minute increment (D9223 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 14, 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 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillofacial surgery under your medical benefit. 
 
You asked the Plan to pre-approve the dental services. You say that your nerves from your missing teeth cause 
a tremendous amount of pain, and your dental services should be covered under your medical benefit. The Plan 
denied your request. The Plan says this services that are dental in nature are not covered under your medical 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The services you are asking the Plan to pre-approve are dental in nature involving the care, treatment, filling, 
removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services 
that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
maxillofacial surgery under your medical benefit.