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

 
We decided that the Plan does not have to pay for the second intraoral x-ray (D0230) and pulp vitality tests 
(D0460) provided on February 11, 2022. 
 
You asked the Plan to pay for the x-ray and pulp vitality tests. You say that these services were necessary, and 
you are unsatisfied with the care provided by this dental office. The Plan denied your request. The Plan says 
pulp vitality tests are not covered by your dental benefit, and your benefit covers a maximum of one intraoral 
x-ray per calendar year. Two intraoral x-rays were provided on the date in question. The first was covered and 
paid for by the Plan, however the second exceeds the frequency limitations of your 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 or were provided in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pay for the second intraoral x-ray (D0230) and pulp 
vitality tests (D0460) provided on February 11, 2022.  
 
Your complaint about the care provided by a Plan-contracted dental provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D62 40) for teeth # 28 and 29, and retainer 
crowns (D6750) for teeth # 27 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that you had to have a tooth extracted. You say 
that your bridge fell out as a result. You say that this has altered your bite. You say that you have now have jaw 
pain and other issues. You also say that you need these services to be covered. The Plan denied your request. 
The Plan says pontics are not listed as covered services. The Plan says that retainer crowns are not listed as 
covered services either. 
 
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 pontics and retainer 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve pontics (D62 40) for teeth # 28 and 29, and retainer crowns (D6750) for teeth # 27 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for services provided on August 31, 2020, and
September 15, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the Plan contract. Maximus partially
overturned the Plans denial because a 2020 Evidence of Coverage had not been provided with the case file. The
Plan requested a reopen and provided the 2020 plan contract.
The Plan was correct in their original decision. 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 cost share for each outpatient diagnostic service. You have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the cost share for services provided on August 31, 2020, and September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the immediate denture - maxillary 
(D5130) provided August 2, 202,1 and the reline complete maxillary denture (indirect) (D5750) and 
extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided August 17, 2021. 
 
You asked the Plan to provide additional payment for the immediate upper denture, upper denture reline and 
tooth extractions. You say that you would like these services paid. The Plan denied your request. The Plan says 
these services have been reprocessed and correctly paid according to your 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 Plan covers the immediate 
upper denture and upper denture reline with 70% coinsurance and tooth extractions with 50% coinsurance. 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have been asked 
to pay 50% of the cost of the tooth extractions and 70% of the cost of the immediate upper denture and upper 
denture reline. Therefore, we decided that the Plan does not have to provide additional payment for the 
immediate denture - maxillary (D5130) provided August 2, 202,1 and the reline complete maxillary denture 
(indirect) (D5750) and extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive this cost share medical services provided from January 4,
2021, to June 21, 2021, under the Medicare benefit.
You asked the Plan to waive this cost share. You say that these services should be covered by the Plan. 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.
The Plan says 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 these services under the Medicare benefit.
Therefore, we decided that the Plan does not have to waive the cost share for medical services provided from
January 4, 2021, to June 21, 2021, under the Medicare benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a replacement CPAP machine due to recall.
You asked the Plan to pre-approve a replacement machine. You say that your equipment was recalled, and the
Plan should replace it. The Plan denied your request. The Plan says enrollees must work with providers to
facilitate the change out or repair of this equipment. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that there was no indication that the equipment provider was unable to
assist with either the repair or replacement of your equipment.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say equipment less than five
years old would be repaired but not fully replaced unless it is completely inoperable. You requested a new
machine due to a provider recall. However, there is no indication that your current equipment was not working
or that you were not being provided loaner equipment by the provider or warrantor while yours is being
repaired due to the recall. The Plan is only required to intercede and pay for replacement equipment from
another provider when the current equipment provider is not able to loan you equipment or fix your current
equipment within a reasonable amount of time. This has not been shown to be the issue in this case. Therefore,
the Plan is not required to provide coverage for a replacement CPAP machine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for these services. You say that at the time of the appeal, skilled
nursing facility services were medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined SNF care was necessary. The Plan requested a reopen and
argues that Medicare does not require a patient to have plateaued in function if the patient is already
functioning at a minimum assist level. The Plan additionally notes that strength training does not require a
SNF, only a home exercise program and a caregiver. The medical records show you have a history of
hypertension, atrial fibrillation, obesity, and hyperlipidemia who suffered a hematoma of her right breast, a
right manubrium fracture, and a closed nondisplaced fracture of the fifth metacarpal. An ulnar gutter splint was
applied. Oral pain medication was ordered. An ACE wrap was to be used as needed for comfort. OT evaluated
on January 3, 2022. Transfers were made with minimal assistance. You were ambulating 40 feet with a
platform walker.
Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support
that it was medically reasonable and necessary to provide skilled therapy services daily in a skilled nursing
facility setting. Therefore, Medicare coverage criteria were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to provide coverage for skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional physical therapy would be 
beneficial for the enrollee's final outcome and help her regain full range of motion. The Plan denied your 
request. The Plan says that they have agreed to pre-approve six of the original twelve visits requested in order 
to finalize a home exercise plan. However, after these six visits the enrollee would be stable to continue 
rehabilitation with the home exercise program and follow-up with their physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that the additional physical therapy requested is medically reasonable and necessary. Our physician reviewer 
found the Plan initially approved 6 additional physical therapy sessions to finalize a home exercise plan; 
however, based on the complexity of the enrollee's injury and the continued lack of range of motion and 
weakness, the full request for 12 visits is reasonable and appropriate. The physical therapist also documents 
reasonable goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve six (6) additional physical therapy (PT) visits.  
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network physical therapy.
You asked the Plan to provide coverage for out of network providers. You say that there is not a network
provider close to your home. The Plan denied your request. The Plan says this provider is not in your primary
care group and you refuse to work with a different group to obtain coverage within the network. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not interpret the contract
correctly regarding Plan providers. The Plan says that you choose to live out of the service area for long
periods of time. The Plan states that this has been discussed with you numerous times and the Plan has offered
to change you to medical groups and primary care providers which are within the geographic area you choose
to spend the majority of your time living in. The Plan states you do not respond to these suggestions. The Plan
is fully within its right, under Medicare rules, to limit enrollees to see providers within their service area.
Finally, if the services had been requested in area, they would have been approved. Since the services were a
foreseen need, they are not covered as an emergency or out of area care issue. The Medicare rules clearly state
an HMO Plan is only obligated to provide routine services in-network.
The Plan is correct in this case. 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 provide coverage for care from out-of-network providers
only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is
not a network provider with the Plan. The Plan has attempted to work with you to be part of a physician group
in the area you live in, and you have refused. We found no exception that would require the Plan to provide
coverage for routine services out of network. Therefore, we decided that the Plan does not have to provide
coverage for out of network physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has to pay for dental services provided by a participating provider on December 13, 
2021, to December 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you have not used your dental services in a long 
time. You say that this should be covered. The Plan denied your request. The Plan says that the maximum 
allowance benefit amount has already been met and 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 failed to provide evidence to verify the enrollee's maximum 
allowance benefit has been met. Therefore, we decided that the Plan has to pay for dental services provided by 
a participating provider on December 13, 2021, to December 22, 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: ER
Decision: Unfavorable

We decided the Plan does not have to pay for emergency room services provided on June 28, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan stated the required billing criteria were not met. Maximus overturned the Plans denial for
insufficient information on the denial. The Plan requested a reopen and provided additional information for
review. The Plan states it has been confirmed the reported taxonomy code is not listed as a valid Medicare
provider.
Additionally, CMS has issued guidance for freestanding emergency departments during the COVID-19 health
emergency. According to CMS, freestanding emergency departments can become authorized temporarily as
hospitals in one of the three following ways: 1. as a hospital affiliated ED under the 1135 emergency waiver, 2.
as Medicaid -certified clinics under the state's clinic benefit, and 3. as a Medicare -certified hospital by
temporarily enrolling in Medicare as a hospital with the attestation process under the 1135 emergency waiver.
The Plan states it has been confirmed this provider is not affiliated with a Medicare/Medicaid-certified hospital
under the temporary expansion 1135 and is not enrolled temporarily as a Medicare/Medicaid certified hospital
to provide hospital services during the COVID-19 Health Emergency. As the servicing provider did not meet
the CMS guidelines for payment, the Plan is unable to pay claims submitted by this facility.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that payment cannot be
made to free standing emergency rooms unless they are affiliated with a hospital and/or been given temporary
status during the pandemic. This provider does not meet either of these criteria. Therefore, we decided that the
Plan does not have to pay for emergency room services provided to the enrollee by the provider on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for two additional epidural steroid injections.
You asked the Plan to provide coverage for two additional injections. You say that these injections are
medically necessary. The Plan denied your request. The Plan says while one injection was approved, additional
injections are not covered. Maximus partially overturned the Plans denial stating one injection was appropriate.
The Plan requested a reopen and stated that Maximus made the same decision the Plan did.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of injection. 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 two
additional injections. Our physician reviewer found only one injection is medically reasonable and necessary
and is compatible with the LCD. Our reviewer stated a second separate injection is not medically reasonable or
necessary. The injectate volume can be increased to cover more levels removing the need for a second
injection. This is also the conclusion the Plan came to, covering one of the injections requested. Therefore, we
decided that the Plan does not have to provide coverage for two additional epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited dental exam (D0140) provided on December 29, 2021. 
 
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says they reviewed your claim history and verified 
on November 22, 2021, you received dental code D0140 with the Plan paying $45 with a $0 member liability. 
The Plan says the frequency limit has been reached for this code for the 2021 benefit year. 
 
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 file and the Plan's contract. The Plan's contract says dental code D0140 is limited to one 
procedure per plan year. The file shows that the Plan paid for dental code D0140 that you received on 
November 22, 2021. Therefore, we decided that the Plan does not have to pay for the limited dental exam 
(D0140) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported removable denture for the lower arch 
(D6111). 
 
You asked the Plan to pre-approve the implant supported denture. You say that you were told the services 
would be covered. You say that you were told it has not been 5 years. You also say that you have only been 
effective with this plan since January 1, 2022. The Plan denied your request. The Plan says the denture received 
in May 2021 can be adjusted to fit the approved implants. 
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 the implant 
supported denture 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 implant supported denture. Our 
reviewer says that the requested denture is not medically necessary. Our physician reviewer found the request 
for a new denture is not medically necessary. The provided documentation indicates that your existing denture 
is less than five years old. Additionally, it has been determined that the existing denture is adaptable to the 
approved mini implants. 
 
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 implant supported denture have not been met. Therefore, we decided that 
the Plan does not have to pre-approve implant supported removable denture for the lower arch (D6111).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the at-home COVID-19 testing kits provided on December 21, 2021.
You asked the Plan to pay for the at-home COVID-19 testing kits. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the counter COVID-19 tests purchased on or after January 15, 2022. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the at-home COVID-19 testing kits have not been met. Specifically, the at-home COVID-19 testing kits were purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 testing kits provided on December 21, 2021.