Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 1, 2023, to July 29, 
2023. 
 
You asked the Plan to pay for podiatry services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says they have not received the required clinical records to 
support the medical necessity of the podiatry services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of podiatry services have been met. The 
Health Plan has not received the required clinical records to support the medical necessity of the podiatry 
services. Therefore, we decided that the Plan does not have to pay for podiatry services provided on April 1, 
2023, to July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  complete series of radiographic images (D0210) provided on 
August 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 24, 2019. 
Therefore, we decided that the Plan does not have to pay for  complete series of radiographic images (D0210) 
provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim must be filed no later than the close of the period 
ending 1 calendar year after the date of service. 
 
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 an office visit was not filed until June 23, 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 an office visit provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral-comprehensive series of radiographic 
images (D0210) provided on August 10, 2023 by an out-of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting that the denial be 
reversed so you can get much needed dental work. 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 an intraoral-comprehensive series of 
radiographic images (D0210) provided on August 10, 2023 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and a crown-porcelain/ceramic 
(D2740) provided on July 6, 2023 to July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this claim to find out why it 
was not paid in full or paid only this amount according to your dental coverage plan. The Plan denied your 
request. The Plan says the services are not covered dental 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 core 
buildup (D2950) and a crown-porcelain/ceramic (D2740) provided on July 6, 2023 to July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 8, 2023, billed with 
codes 81231, 81232, 81306, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 8, 2023, billed with codes 81231, 81232, 81306, and 81335.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a positron emission tomography PET/CT scan
for the enrollee.

You asked the Plan to provide coverage for a PET/CT scan. You say that at the time of the appeal, this imaging
was 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 the records show the enrollee is a 70-year-old with diagnosis of breast
cancer in July 2008 and mastectomy performed in 2009. Final staging was "IIIA disease".

The enrollee had a pulmonary recurrence in 2017 and was started on chemotherapy at that point. Beginning in
September 2021, the enrollee has had four serial PET/CT scans, all of which have shown a complete response,
including the most recent on March 22, 2023. There are no current symptoms reported in the medical records.
Medicare criteria are not met.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare typically covers 3 additional PET scans after the initial staging. The
medical records provided do not support additional scans. Therefore, we decided that the Plan does not have to
provide coverage for a positron emission tomography (PET) scan with computed tomography (CT) scan for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, premolar tooth (excluding final 
restoration) (D3320), provided on August 25, 2023, and August 26, 2023. We also decided that the Plan does 
not have to pay for the prefabricated post and core in addition to crown (D2954) provided on August 25, 2023, 
and August 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were informed by the dentist that your 
insurance would cover up to $1,000 and your deductible is $0. You also say that you are being charged $400 
because the dentist states he does not work directly with your plan.  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, and for dental conditions 
that have two or more possible treatments if you choose to receive a higher cost treatment, you will be 
responsible to pay for the difference. The Plan also says that prefabricated post and core are not covered under 
your dental 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. 
 
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 endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) provided on August 25, 2023, and August 26, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated post and core are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prefabricated post and core in addition to crown (D2954) provided on August 25, 2023, and August 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110), the complete lower 
denture (D5120), and the unspecified removable prosthodontic procedure (D5899) provided on the August 31, 
2023. 
 
You asked the Plan to pay for the complete upper denture (D5110), the complete lower denture (D5120), and 
the unspecified removable prosthodontic procedure (D5899). You say that you were told that your plan covers 
50% of dentures. The Plan denied your request. The Plan says the services are not covered benefits. However, 
due to the misinformation you were given, the Plan agreed to pay for the dentures at 50% coinsurance up to the 
maximum dental allowance of $2,000 for comprehensive dental 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 the 
complete upper denture (D5110), the complete lower denture (D5120), and the unspecified removable 
prosthodontic procedure (D5899) provided on the August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 27, 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 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 dental services provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64495 billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for procedure code 64495. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors shall automatically deny claim line(s) 
items submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64495 have not been met. Specifically, code 64495 has been reported with a GZ 
modifier. Therefore, we decided that the Plan does not have to pay for procedure code 64495 billed for date of 
service June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87640, 87651, and 87481 billed for 
date of service September 1, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87640, 87651, and 87481. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for code 87798, 87640, 87651, and 
87481 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 87798, 87640, 87651, and 87481 is a column II code to column I 
code 87801. While these codes were billed with modifier -59, the medical records provided do not show that 
the service billed with the -59 modifier is a distinct procedural service. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87798, 87640, 87651, and 87481 billed for date of service September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230) provided on August 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 4, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral- periapical each additional radiographic 
image (D0230) provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for established patient home or residence services. provided on 
April 13, 2023. 
 
You asked the Plan to pay for established patient home or residence 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 established patient home 
or residence services. provided on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81284 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for procedure code 81284. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 81284 is bundled into 
payment for code 81286. 
 
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, we have confirmed that code 81284 
is a column II code to column I code 81286. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81284 billed for date of service October 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit and saline solution
infusions provided on December 7, 2022.

You asked the Plan to waive cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract rules.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay cost share for each service
rendered a specialist office visit and Medicare Part B drugs.

You have been asked to pay cost share for each service rendered for this cost share. 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
cost share for the specialist office visit and saline solution infusions provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), 
prophylaxis-adult (D1110) and the topical application of fluoride (D1208) provided on July 10, 2023 by an out-
of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were told your provider was contracted. 
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 a periodic oral evaluation (D0120), bitewings (D0274), prophylaxis-adult (D1110) and the topical 
application of fluoride (D1208) provided on July 10, 2023 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET/CT scan for the enrollee.

You asked the Plan to provide coverage for a PET/CT scan. You say that at the time of the appeal, this imaging
was 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 computed tomography scan from July 10, 2023, a right middle lobe
opacity representing "scarring and/or subsegmental atelectasis. No definable mass."

It was also noted there was "no significant change in mildly enlarged pre-carinal and right hilar lymph nodes."
There is no mention of a right upper lobe mass, a right lower lobe nodule, or any other mass. The interpreting
radiologist recommendation is "follow-up chest CT scan in 6 to 9 months." There is no evidence of malignancy
and no basis for ordering a PET/CT scan.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that for Medicare to
consider coverage and payment for any item or service, the information submitted by the supplier or provider
must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare
coverage criteria have been met. Medicare has specific coverage criteria for PET scans. Based on the medical
records provided, there is no indication as to why a PET scan was requested. The records provided do not
support a suspicion of cancer and there is no biopsy present to confirm cancer. Medicare coverage criteria were
not met at the time of the appeal. Therefore, we decided the Plan does not have to provide coverage for a
positron emission tomography (PET) scan concurrently with a computed tomography (CT) scan of the skull
base to mid-thigh for the enrollee.