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

 
We decided that the Plan does not have to pay for teeth cleaning (D1110) provided on May 24, 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 dates of service June 30, 2021, and 
November 11, 2021. Therefore, we decided that the Plan does not have to pay for teeth cleaning (D1110) 
provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual wheelchair accessory, side guards (K0108x2) 
and leg strap (K0038). 
 
You asked the Plan to pre-approve side guards and leg strap. You say that you would like reconsideration for 
the denied accessories. The Plan denied your request. The Plan says side guards are more of a convenience 
item than medical necessity and leg straps are not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve manual wheelchair accessory, side guards (K0108x2) and 
leg strap (K0038).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D3950, D3910, D2799, D6190, 
D0383). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no signs that more than half the teeth have damage from decay or injury. 
 
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 Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found that the 
procedures in question (D3950, D3910, D2799) are all included in the approved treatment for a crown 
restoration for tooth #18. D6190 would be part of the implant procedure and a cone beam of one arch (D0382) 
appears to be adequate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D3950, D3910, D2799, D6190, D0383).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter COVID-19 tests purchased from January 20, 2022, to February 12, 2022.
You asked the Plan to pay for the COVID-19 home tests. You say that the Plan should cover this testing. The Plan denied your request. The Plan says this testing was not covered under the Plan benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan must follow Medicare rules. Medicare rules in place at the time you purchased these tests indicate that over the counter testing was not covered by either Medicare or the Plan for direct reimbursement. You did not contact the Plan for direction prior to making these purchases. Therefore, we decided that the Plan does not have to pay for over the counter COVID-19 tests purchased from January 20, 2022, to February 12, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter COVID-19 tests purchased on April 16, 2022.
You asked the Plan to pay for the COVID-19 home tests. You say that these tests should be covered by the Plan. The Plan denied your request. The Plan says this testing was not covered under the Plan benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
The Plan must follow Medicare rules. Medicare rules in place at the time you purchased these tests indicate that over the counter testing was not covered by either Medicare or the Plan for direct reimbursement. You did not contact the Plan for direction prior to making this purchase. Therefore, we decided that the Plan does not have to pay for over the counter COVID-19 tests purchased on April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist (99204) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with an oncologist. You say that you have a history of 2 types 
of cancer and have undergone various treatments. Your previous oncologist is no longer available to you, and 
you were instructed to get a replacement for further monitoring and PET scans, etc. The OON provider's 
medical education at UCLA, his acceptance with the Plan, his proximity and willingness to accept new 
patients, and the recommendation of him by a physician friend who is also a cancer patient, resulted in this 
appeal. The Plan denied your request. The Plan says the requested service (oncology follow up) is available in 
network and can be provided at a community level specialist. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with an oncologist (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for podiatry services provided to the enrollee on October 25, 2021 under the Medicare benefit.
You asked the Plan for to pay for these services. 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 podiatry services provided to the enrollee on October 25, 2021 under the Medicare benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-intravenous conscious sedation (D9248) provided on 
March 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that this was the best option for recovery. You say 
that it is a necessary part of the procedure. You also say that it helps with your nervousness. The Plan denied 
your request. The Plan says non-intravenous conscious sedation is not listed as 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 non-intravenous conscious sedation 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
non-intravenous conscious sedation (D9248) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond inlay, onlay, veneer or partial coverage 
restoration (D2910) provided on February 24, 2022. 
 
You asked the Plan to pay for re-cement or re-bond inlay, onlay, veneer or partial coverage restoration. You 
say that the service was necessary. The Plan denied your request. The Plan says the service at issue 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 re-cement 
or re-bond inlay, onlay, veneer or partial coverage restoration (D2910) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(CPT code 64484-50). 
 
You asked the Plan to pre-approve the injection. You say that this procedure is medically necessary for the 
enrollee because they have been in chronic pain for over three (3) years and feel given the positive response 
from previous injections the enrollee and you feel this is medically necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the injection have not been met. The rules say that transforaminal 
epidural steroid injections (TFESIs) involving a maximum of two (2) levels in one spinal region are considered 
medically reasonable and necessary. 64483-50 is already approved at the same setting. It is important to 
recognize that most conditions would not ordinarily require ESI at two (2) levels in one spinal region and no 
more than 2 TFESIs should be performed at a single setting (eg, single level bilaterally or two levels). The rule 
limits injection to one (1) bilateral per session. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, each additional level (CPT code 64484-50).
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), resin-based composite (D2393), endodontic therapy (D3320), and the removal of residual tooth roots 
(D7250 x 4) provided on March 10, 2022. 
 
You asked the Plan to pay 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 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 Plan's coverage rules apply in this case. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the intraoral-complete series of radiographic images (D0210), resin-based composite (D2393), endodontic therapy 
(D3320), and the removal of residual tooth roots (D7250 x 4) provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 units of procedure code 92522 billed on January 26, 2022, 
and February 2, 2022. 
 
You asked the Plan to pay for procedure code 92522. You say that these services were medically necessary, 
and the enrollee would be harmed without it. The Plan denied your request. The Plan says procedure codes 
92507 and 97535 were paid. The Plan also says that procedure code 92522 has an MUE value of 1 but 4 units 
were billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92522 is 1. The MAI value for this code is 2. You billed 2 units of this 
code on each date of service, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 92522 have not been met. Therefore, we decided that the Plan does not have to 
pay for 4 units of procedure code 92522 billed on January 26, 2022, and February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on April 5, 2022. 
 
You asked the Plan to pay for a core buildup. You say that that the procedure was covered at the time you 
signed up and that you were never told that there would be changes to the coverage. The Plan denied your 
request. The Plan says the service at issue 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 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 core 
buildup (D2950) provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 27, 2021, billed with 
codes 81238, 81230, 81291, 81225, 81241 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare rules. 
 
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 27, 2021, billed with codes 81238, 81230, 81291, 81225, 81241 and 81240.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 81286, 81413, 81414, 81442 and 81479. We decided 
that the Plan does not have to pay for procedure code 81400.  
 
You asked the Plan to pay for procedure code 81400 and for procedure codes 81286, 81413, 81414, 81442 and 
81479. You say that you have provided documentation to support the services billed. The Plan says that 
payment for code 81400 is bundled into payment for code 81413. The Plan also says that rules for payment for 
procedure codes 81286, 81413, 81414, 81442 and 81479 have not been met because the procedures at issue are 
screening procedures. 
 
We decided that the Plan has to pay for procedure codes 81286, 81413, 81414, 81442 and 81479.  
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case record does not include medical documentation to support 
that the enrollee has no signs or symptoms of cardiovascular disease. Without supporting medical 
documentation, procedure codes 81286, 81413, 81414, 81442 and 81479 cannot be verified to be screening 
procedures. No further denial rationale is evident in the case record. It is the Plans responsibility to 
substantiate its denial. In this case, the denial has not been substantiated, so we must find in your favor 
regarding procedure codes 81286, 81413, 81414, 81442 and 81479. Therefore, we decided that the Plan has to 
pay for procedure codes 81286, 81413, 81414, 81442 and 81479.  
 
We also decided that the Plan does not have to pay for procedure code 81400. 
 
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 81400 
is a column II code to column I code 81413. 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 81400. 
 
  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 has paid the full $1,000 dental benefit for services provided on May 3, 2022, and May 
9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not given accurate information when 
you contacted the Plan prior to your visit. 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 May 9, 2022. Therefore, 
we decided that the Plan has paid the full $1,000 dental benefit for services provided on May 3, 2022, and May 
9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal axial rotational unit represented by code 
L5984 and an endoskeletal pylon device that allows vertical shock reduction represented by code L5988. 
 
You asked the Plan to pre-approve codes L5984 and L5988. You say that this is not a K1 individual and would 
greatly benefit from a K2 level foot and the requested accessories. The Plan denied your request. The Plan says 
an endoskeletal pylon device that allows vertical shock reduction exceeds the enrollee's needs. The Plan says 
that an endoskeletal axial rotational unit represented by code L5984 is part of a prosthetic foot. It does not 
constitute a complete prosthetic foot and must be used in combination with a base foot code. 
 
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 L5984 and L5988. Our reviewer 
says that the items which remain in dispute are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the L5988 is a vertical shock reducing pylon and the physician documentation 
does not reveal that the enrollee is participating in high impact activities or that the patient requires this feature.  
L5984 is an additional feature and/or function that does not describe a complete prosthetic foot. The physician 
documentation does not reveal that the enrollee requires the L5984 axial rotation unit. 
 
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 L5984 and L5988 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an endoskeletal axial rotational unit represented by code L5984 and an 
endoskeletal pylon device that allows vertical shock reduction represented by code L5988.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for crowns (D2740 x2) provided on March 
3, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you want the Plan to pay 
for the service. 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 you have used the benefit allowed limit of $3,000. After the maxed benefit allowed is exhausted, any 
remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay an 
additional amount for crowns (D2740 x2) provided on March 3, 2022.