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

We decided that the Plan does not have to waive the cost share for the technetium (A9500) and the regadenson
injection (J2785) or the copayments for the ultrasound, stress test, and myocardial perfusion imaging provided
on November 18, 2021, and December 1, 2021.
You asked the Plan to waive the cost-sharing for the technetium (A9500), regadenson injection (J2785),
ultrasound, stress test, and myocardial perfusion imaging. You say that these services were approved. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus partially overturned the
Plans denial by waiving the coinsurance for the technetium (A9500) and the regadenson injection (J2785). The
Plan requested a reopen for the technetium and the regadenson injection.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for each Medicare-covered medical supply. You have been asked to pay a 20% coinsurance for the
technetium (A9500) and the regadenson injection (J2785). These items fall within the Medicare-covered
medical supply benefit category. You have been asked to pay a $160 copayment for an ultrasound on
November 18, 2021. You have also been asked to pay a $30 copayment for a stress test and a $160 copayment
for myocardial perfusion imaging on December 1, 2021. An ultrasound, stress test, and myocardial perfusion
imaging fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.
This means that 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 coinsurance for the technetium (A9500) and the regadenson injection
(J2785) or the copayments for the ultrasound, stress test, and myocardial perfusion imaging provided on
November 18, 2021, and December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
November 19, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not understand
why the bill was not paid. The Plan denied your request. The Plan says that you have been charged the correct
cost sharing amount.
Maximus overturned the Plan's 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 waive the copayment for the specialist office visit
provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray, dental cleaning, and complete oral 
examination provided on March 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the dental work was 
denied. You say you want the services to be covered. The Plan denied your request. The Plan says your 
contract clearly states that there is a $1,500 combined dental allowance for supplemental preventive and 
comprehensive dental services. The Plan determined that you had already met your yearly maximum allowance 
at the time of 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, certain limitations apply. The record 
shows that your benefit for the requested items or services was exhausted on March 11, 2022. The Plan paid 
some services at the time of service; however, the annual maximum was reached. This left the services at issue 
unpaid, and payment of the remaining services is your responsibility. Therefore, we decided that the Plan does 
not have to pay for a panoramic x-ray, dental cleaning, and complete oral examination provided on March 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia each subsequent 15-
minute increment (D9223) x4. 
 
You asked the Plan to pre-approve dental services. You say that you are currently in pain and would not be able 
to afford the cost of requested service. The Plan denied your request. The Plan says this service is not covered 
under your 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. Deep sedation/general 
anesthesia each subsequent 15-minute increment is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested deep sedation/general 
anesthesia each subsequent 15-minute increment (D9223) x4 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia each 
subsequent 15-minute increment (D9223) x4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant-supported porcelain/ceramic crown in tooth 
spaces #18, #19, and #30; and a custom-made abutment with placement of tooth spaces #18, #19, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the claim was processed correctly. The requested services and 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 pre-approve an 
implant-supported porcelain/ceramic crown in tooth spaces #18, #19, and #30; and a custom-made abutment 
with placement of tooth spaces #18, #19, and #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from May 5, 2021, to May 28, 
2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you believe you filed these claims timely. 
The Plan denied your request. The Plan says this claim denied because the claims for these dates of service 
were not timely filed and because x-rays and mechanical traction services are not covered chiropractic services. 
 
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 the 
chiropractic services was not filed until May 31, 2022. 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 chiropractic services provided from May 5, 2021, to May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated on tooth # 32 (D7210). The Plan 
has agreed to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and 
including elevation of mucoperiosteal flap if indicated for tooth #21 and the limited oral evaluation - problem 
focused (D0140) provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was not in-
network. The Plan says after review, the dental claim was reprocessed paying for the surgical removal of tooth 
#21 and the limited oral evaluation. Your benefit for the extraction, erupted tooth requiring removal of bone 
and/or sectioning and including elevation of mucoperiosteal flap if indicated of tooth #32 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 erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210) was exhausted on date of service June 1, 2022. Therefore, 
we decided that the Plan does not have to pay for the extraction on tooth #32 provided on June 1, 2022. The 
Plan has agreed to pay for the erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated on tooth #21 and the limited oral evaluation - problem focused 
(D0140) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental procedure done 
because it helps with your teeth. 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 the date of service of May 25, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage implant surgery on tooth #13 and 14 
(D6011). 
 
You asked the Plan to pre-approve implant surgery. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says second stage implant surgery (D6011) is not covered by 
your dental 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 pre-approve 
second stage implant surgery on tooth #13 and 14 (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for the enrollee to 
receive this dental procedure. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because partial dentures are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) and drugs 
dispensed in office (D9630) provided by a participating provider on June 2, 2022, to June 13, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots and drugs dispensed in office. You say that 
the tooth had a crown which broke off leaving the tooth exposed to bacteria, and you had to have it removed 
for your health. The Plan denied your request. The Plan says the rendered dental services are not covered 
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 
removal of residual tooth roots (D7250) and drugs dispensed in office (D9630) provided by a participating 
provider on June 2, 2022, to June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says an authorization is required for non-emergency 
Medicare covered 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. 
 
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 the dental services on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from October 17, 2021, 
through October 21, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says self-administered drugs given in the 
hospital are not covered under the enrollee's medical benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from October 17, 2021, through October 21, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided by an out-of-network 
provider on June 2, 2022. 
 
You asked the Plan to pay for pulp vitality tests. You say that you would like the Plan to pay for these services. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulp 
vitality tests (D0460) provided by an out-of-network provider on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture - cast metal 
framework with resin denture bases (D5224). 
 
You asked the Plan to pre-approve an immediate mandibular partial denture - cast metal framework with resin 
denture bases (D5224). The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
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 pre-approve an 
immediate mandibular partial denture - cast metal framework with resin denture bases (D5224).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided from October 1, 2021, 
to October 29, 2021. 
 
You asked the Plan to pay for therapy services. You say that you should not be responsible for these bills. The 
Plan denied your request. The Plan says the therapy services are not covered without prior authorization. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient therapy services provided from October 
1, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling (D2332) on tooth #11 
provided on November 17, 2021. 
 
You asked the Plan to pay for restorative dental services. You say that you were under the assumption that you 
were still enrolled in the supplemental dental benefit. The Plan denied your request. The Plan says the claim 
was processed correctly. At the time of service, you were only covered for basic preventive dental services. 
The Plan offers an optional supplemental dental benefit that you must sign up for. Please note, you may be 
required to pay an additional premium for these benefits. You were not enrolled in these additional benefits at 
the time of service, therefore, the Plan denied coverage. 
 
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, you were not enrolled in the optional 
supplemental dental benefits on the date of service. Therefore, we decided that the Plan does not have to pay 
for a resin-based composite filling (D2332) on tooth #11 provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6065) and prefabricated abutments (D6056) 
for tooth #4, #5, #6, #7, #10, #11, #12, #13, #22, #23, #25, #26, and #27. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee to 
get these dental procedures done. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because dental implants and all associated services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implants (D6065) and prefabricated abutments (D6056) for tooth #4, #5, #6, #7, #10, #11, #12, #13, #22, #23, 
#25, #26, and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270), a limited oral evaluation (D0140), and a 
periapical x-ray (D0230), provided by a participating provider on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. 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 D0270 was exhausted on date of service July 23, 2021, D0140 was exhausted on 
January 28, 2022, and D0230 was exhausted on May 11, 2022. Therefore, we decided that the Plan does not 
have to pay for bitewings (D0270), a limited oral evaluation (D0140), and a periapical x-ray (D0230), provided 
by a participating provider on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the removal of plaque (D1110) provided on March 17, 
2022 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 removal of plaque (D1110) provided on 
March 17, 2022