Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for inpatient services provided from May 19, 2021, to May 21, 2021.
You asked the Plan to pay for these services under the Medicare benefit. You say that you do not believe this
bill is correct. The Plan denied your request. The Plan says these services must be addressed under your
Medicaid benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan says that this claim denied under your Medicare benefit because you are Medicaid
eligible. The Plan included documentation to show that you are Medicaid eligible. The Plan says that Medicare
pays covered dually eligible beneficiaries' medical services first, because Medicaid is generally the payer of
last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing
home care, personal care, and home- and community-based services). These services qualified under the
Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for inpatient services provided from May 19, 2021, to
May 21, 2021, under the Medicare benefit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88104, 88305, 88312, 88361) provided August 
20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88104, 88305, 88312, & 88361 is not supported in the medical record. Specifically, the 
services have a professional component / technical component of 1. Services were provided in an outpatient 
setting. Payment for these services is made to the outpatient hospital. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for lab services (88104, 88305, 88312, 88361) 
provided August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) on April 21, 2022. 
 
You asked the Plan to pay for periodontal maintenance (D4910). You say that you were advised that this 
service would be covered. The Plan denied your request. The Plan says the 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 
periodontal maintenance (D4910) on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99213) provided on January 6, 2022. 
 
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for physician services (99213) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D5211, D5214, D1999) on March 25, 2022. 
 
You asked the Plan to pay for dental services (D5211, D5214, D1999). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says our records indicate the member did 
contact the plan prior to the date of service to verify benefits and provider eligibility. On this call, benefit 
information was given, and the caller was informed that the services were not 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 dental 
services (D5211, D5214, D1999) on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service 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 June 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a residual limb volume management system represented 
by code L5781. 
 
You asked the Plan to pre-approve codes L5781. You say that all requirements for coverage are met. You say 
that the item which remains in dispute is needed in order to live independently. The Plan denied your request. 
The Plan says there are only a few publications in the literature that examine the efficacy of the vacuum 
assisted socket system (VASS.) The Plan says that the sample sizes of these studies are relatively small. The 
Plan says that these studies did not demonstrate that the use of VASS provided consistent statistical clinical 
significance. 
 
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 codes L5781. Our reviewer says that 
the item which remain in dispute are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an addition to lower limb prosthesis, vacuum pump, residual limb volume 
management and moisture evacuation system exceeds the enrollee's medical needs and is not proven superior to 
a standard socket. Further research is needed with clinical trials that recruit larger sample sizes and report long-
term outcome data for the requested elevated vacuum suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5781 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a residual limb volume management system represented by code L5781.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records show the enrollee will not 
need LTACH services for 25 or more days. The enrollee's medical condition is less than the level of care 
provided at an LTACH. The enrollee's needs may safely be met at a skilled nursing facility or home health 
services with supervision at home. 
 
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 that the enrollee appears to be improving but with an unstable feeding source 
inappropriate for transfer at this time. The enrollee should only require short-term additional acute care services 
that can safely be administered at the current facility until more appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer 
and as it would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended. 
 
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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75726 billed for date of service October 11, 2021. 
 You asked the Plan to pay for procedure code 75726. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 75726 
is a column II code to column I code 37242. 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.  
 
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 36160 is introduction of needle or intracatheter, aortic, 
translumbar. 
 
We find that CPT code 36160 is not supported in the medical record. Specifically, there is no documentation of 
introduction of aortic or translumbar needle or intracatheter.  
 
Therefore, we decided that the Plan does not have to pay for procedure code 75726 billed for date of service 
October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty-one to three contiguous 
teeth bounded spaces per quadrant (D4211) provided on April 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingivectomy 
or gingivoplasty-one to three contiguous teeth bounded spaces per quadrant (D4211) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the denial should be reversed, and the claim 
should be paid. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service May 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical 
x-ray (D0220) provided May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 27, 2022. 
 
You asked the Plan to pay for an evaluation. You say that this provider is in-network. The Plan denied your 
request. The Plan says a limited oral evaluation (D0140) is not covered by your routine dental benefits. 
 
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, 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 limited 
oral evaluation (D0140) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service May 15, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), the periodic oral 
evaluation (D0120), and the bitewing x-rays-four radiographic images (D0274) provided on May 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the dental cleaning (D1110), the periodic 
oral evaluation (D0120), and the bitewing x-rays-four radiographic images (D0274) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation - limited, problem focused exam (D0170) 
provided on April 6, 2022. 
 
You asked the Plan to pay for the re-evaluation exam. You say that following dental surgery, this was a follow 
up visit for new symptoms. The Plan denied your request. The Plan says the service provided is not a covered 
benefit 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. 
 
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 re-
evaluation - limited, problem focused exam (D0170) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 10, 2022, to 
January 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you could not afford to have the implant back 
home. The Plan denied your request. The Plan says these services are not covered outside the United States. 
 
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 when received outside the United States. Therefore, we decided that the 
Plan does not have to pay for the dental services provided from January 10, 2022, to January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #4 (D2391) provided 
on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to have a filling replaced, and that 
you should not be responsible for the charges. 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 April 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite filling on tooth #4 
(D2391) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit - after regularly scheduled hours (D9440) 
provided May 2, 2022. 
 
You asked the Plan to pay for the after-hours office visit. You say that you went to your dentist because of 
severe pain. The Plan denied your request. The Plan says this service is not covered under your 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 office 
visit - after regularly scheduled hours (D9440) provided May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) 
provided July 7, 2021. 
 
You asked the Plan to pay for the crown. You say that you did not know there were different types of coverage 
for different plans. The Plan denied your request. The Plan says this service is not covered under your 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 crown 
- porcelain fused to high noble metal (D2750) provided July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on June 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
complete series of radiographic images (D0210) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns on tooth #2, 3, 4, and 5 (D2710) provided on March 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had seen on a television commercial that 
dental services were unlimited. 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 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 requested item or service was exhausted on date of service April 29, 2021. 
Therefore, we decided that the Plan does not have to pay for crowns on tooth #2, 3, 4, and 5 (D2710) provided 
on March 2, 2022.