Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code D0150) and 
the panoramic image (dental code D0330) provided on January 31, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and the panoramic image. You say that you 
were sent to a new dentist and these services were a part of their evaluation. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because one evaluation and panoramic image is 
covered every 3 plan years and you previously received an evaluation and panoramic image on July 24, 2019. 
 
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 1 evaluation 
and 1 panoramic image every 3 plan years. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received a covered evaluation and 
panoramic image on July 24, 2019; therefore, the benefit was exhausted for date of service January 31, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code 
D0150) and the panoramic image (dental code D0330) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (dental code D9310) and a cone beam CT 
capture and interpretation with limited field of view - less than one whole jaw (dental code D0364) for tooth 
#18 provided on February 24, 2022. 
 
You asked the Plan to pay for a consultation and a cone beam CT capture and interpretation with limited field 
of view - less than one whole jaw. You say that the dentist needed to do the procedures to diagnose your tooth 
pain. The Plan denied your request. The Plan says these services are not covered by the Plan's 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 
consultation (dental code D9310) and a cone beam CT capture and interpretation with limited field of view - 
less than one whole jaw (dental code D0364) for tooth #18 provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code D0150) for 
tooth #1 through #32 provided on February 26, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was the first time you used 
the dental insurance. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because one evaluation is covered every 3 plan years and you previously received an evaluation on 
November 24, 2021. 
 
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 1 evaluation 
every 3 plan years. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received a covered evaluation on 
November 24, 2021; therefore, the benefit was exhausted for date of service February 26, 2022. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code D0150) for tooth 
#1 through #32 provided on February 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral examination (dental code D0120), bitewings - 
four radiographic images (dental code D0274), and prophylaxis - adult (dental code D1110) provided on March 
17, 2021. 
You asked the Plan to pay for a periodic oral examination, bitewings - four radiographic images, and 
prophylaxis - adult. You say that you should be able to see any dentist since Medicare does not have dental 
benefits. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for 
items or services provided directly by a physician or practitioner who has opted out of the program except in cases 
involving emergencies or urgently needed care. The Plan contract says that supplemental dental services are covered 
when provided by any licensed dental provider who accepts Medicare patients in the United States and has not 
opted out of Original Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has 
opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a periodic oral 
examination (dental code D0120), bitewings - four radiographic images (dental code D0274), and prophylaxis 
- adult (dental code D1110) provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical extraction of tooth #6 and 11 (D7210), extraction on 
tooth #7, 8, and 9 (D7140), and deep sedation (D9222, D9223 x 2) provided on January 26, 2022. 
 
You asked the Plan to pay for extractions and deep sedation. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says surgical extractions (D7210), extractions (D7140), 
and deep sedation (D9222, D9223) are not covered by your supplemental 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 surgical extraction of tooth 
#6 and 11 (D7210), extraction on tooth #7, 8, and 9 (D7140), and deep sedation (D9222, D9223 x 2) provided 
on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiopharmaceutical imaging (78803 additional unit).
You asked the Plan to pay this claim. The Plan denied your request. The Plan says this was a duplicate claim.
Maximus overturned the Plans denial stating the records showed this service was medically necessary. The
Plan requested a reopen and stated the issue was not medical necessity but the fact that the services were
previously paid. The Plan says that this was an administrative determination for a billing error. The Plan stated
the enrollee had a professional interpretation of a SPECT brain scan on August 11, 2021. The submitted
documentation supports 1 (one) unit of 78803-26, which was previously approved and paid to the provider.
There is no additional documentation supporting an additional study was performed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case the records show this claim was previously paid to the same provider.
There is no documentation to show additional services were provided. Medicare rules for coverage of this
claim have not been met. Therefore, we decided that the Plan does not have to pay for radiopharmaceutical
imaging (78803 additional unit) provided to the enrollee on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210), provided by a participating provider on February 10, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral imaging. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0150 and 
D0210 have already been met and 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. The Plan covers a 
comprehensive oral evaluation and intraoral imaging when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0210 were 
provided on August 10, 2021, and August 21, 2021. Based on this information, we decided that the Plan's rules 
for coverage of a comprehensive oral evaluation and intraoral imaging have not been met. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral imaging 
(D0210), provided by a participating provider on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292, 81301) provided 
on November 1, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292, 81301) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported retainer for tooth number 19 
(D6070) and a prefabricated abutment for tooth number 19 (D6056). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment 
supported retainer for tooth number 19 (D6070) and a prefabricated abutment for tooth number 19 (D6056).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292, 81301) provided 
on May 23, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292, 81301) provided on May 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for repairs for a stair lift.
You asked the Plan to pay for repairs for a stair lift. You say that your stair lift required repair, and you are
asking the Plan to pay for those repairs. The Plan denied your request. The Plan says stair lifts in general are
not covered by Medicare, therefore repairs to a stair lift would not be covered. Maximus upheld the Plans
denial stating the issue was a new stair glide which is not covered by Medicare. You requested an ALJ hearing
to review your appeal stating there were errors in our review. The ALJ remanded the case back to Maximus to
review for repairs and not replacement.
Upon second review of the appeal, we continue to find the Plan is correct in this case. Medicare rules state that
stair lifts are not covered because they are not primarily medical in nature.
This would also include repairs to a stair lift. While a stair lift may be appropriate for your use, neither the Plan
nor Medicare pays for repairs, batteries, or maintenance for equipment that is not covered by Medicare in
general. Therefore, we decided that the Plan does not have to pay for repairs for a stair lift provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation on March 1, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says it was determined the limited 
oral evaluation was appropriately processed to deny payment according to the member's EOC. 
 
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 
limited oral evaluation on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on December 16, 
2021. We also decided that the Plan does not have to pay for the intraoral-periapical first radiographic image 
(D0220), the intraoral-periapical each additional radiographic image (D0230), and the 2D oral/facial 
photographic image (D0350) provided on December 16, 2021.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan says the services provided in this case are not payable.  
 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on 
December 16, 2021. The Plan contract states that an exam is covered once every three years. The Plan has 
stated that you had exhausted this benefit as you received a comprehensive oral evaluation previously on  
June 12, 2019. However, the Plan did not provide proof that this service was rendered and paid for by the Plan. 
Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward 
information to the Independent Review Entity (IRE). The Plan has not substantiated their denial; therefore, we 
must find in your favor. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation 
provided on December 16, 2021.  
 
We also decided that the Plan does not have to pay for the intraoral-periapical first radiographic image 
(D0220), the intraoral-periapical each additional radiographic image (D0230), and the 2D oral/facial 
photographic image (D0350) provided on December 16, 2021. The contract says that the Plan covers certain 
dental services as a supplemental (extra) benefit. This benefit includes exams, bitewing x-rays, cleanings, and 
anesthesia. Intra-oral periapical x-rays and 2D oral/facial photographic images are not covered. Therefore, we 
decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), the 
intraoral-periapical each additional radiographic image (D0230), and the 2D oral/facial photographic image 
(D0350) provided on December 16, 2021 . 
 
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: Favorable

 
We decided that the Plan has to pay for a crown (D2790) on tooth #19 provided on February 7, 2022. 
 
You asked the Plan to pay for a crown. You say that the crown is medically necessary since the enrollee has 
cracked tooth syndrome. The Plan denied your request. The Plan says that the medical records did not show the 
enrollee had cracked tooth syndrome and did not explain why this fracture could not be fixed with a filling. 
 
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 a crown 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 pay for a crown. Our reviewer says that the 
documentation meets the criteria for coverage for a crown restoration for tooth #19. Our physician reviewer 
found the documentation indicates the presence of an occlusal restoration with apparent fractures extending 
mesial and distal from the restoration. The clinical symptoms such as, pain with biting pressure and cold 
sensitivity, indicates a cracked tooth. Our physician reviewer also says the standard of care is the placement of 
a crown restoration to prevent further fracture which could lead to possible loss of the tooth. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pay for a 
crown (D2790) on tooth #19 provided on February 7, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for the complete series dental x-ray provided on February 21, 2022, billed 
with code D0210. 
 
You asked the Plan to pay for the complete x-ray series. You say that you did not realize there was any 
limitation for this benefit. The Plan denied your request. The Plan says that you were provided with a complete 
series of x-rays on March 3, 2020, meaning this benefit is 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided evidence to support that the complete series coded as 
D0210 was covered previously. It was noted that D0210 was provided on March 3, 2020; however, review of 
the documentation shows that a periodic oral evaluation coded D0120 was provided that day. There is no 
documentation showing that D0210 was provided. Without such evidence, we find that this denial is incorrect. 
Therefore, we decided that the Plan has to pay for the complete series dental x-ray provided on February 21, 
2022, billed with code D0210.  
 
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 the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) and the endodontic therapy, of a molar tooth (excluding final restoration) 
(D3330) rendered by the out-of-network (OON) provider on July 17, 2021 and September 28, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network dental provider; therefore, the services are not covered. 
 
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.   
  
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the dental services were rendered by an out-of-
network dental provider. The Plan contract states that mandatory supplemental dental benefits are provided 
through the Plan. Additionally, the dental chart indicates that you pay 100% of the cost for any services 
received from an out-of-network dental provider. Therefore, we decided that the Plan does 
not have to pay for the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) and the endodontic therapy, of a molar tooth (excluding final restoration) (D3330) rendered by the 
out-of-network (OON) provider on July 17, 2021 and September 28, 2021.