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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 14, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that you were examined the 
same way you always were, and it was always covered. The Plan denied your request. The Plan says the 
service exceeds the frequency limitation in the benefit plan. 
 
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, you also has a maximum benefit of one 
comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation 
provided on July 8, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy provided on December 9, 2019. 
 
You asked the Plan to pay for endodontic therapy. You say that you cannot afford a $770 dental bill. You say 
that the bill should be paid because you were under the impression it would be taken care of. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0365) and 
problem focused limited oral evaluation (D0140) provided on February 10, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral 
evaluation. You say that the dentist needed to do these x-rays. You also say that The Plan denied your request. 
The Plan says cone beam CT capture and interpretation is not a covered benefit under your dental plan. The 
Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in the benefit 
plan. 
 
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, cone beam CT capture and 
interpretation is not among those covered under this benefit. The contract also clearly states that problem 
focused limited oral evaluation (D0140) is a covered benefit, and is limited to one procedure per plan year. The 
record shows that you received a problem focused limited oral evaluation on March 12, 2020 and your problem 
focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the cone beam CT capture and interpretation (D0365) and problem focused limited oral 
evaluation (D0140) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complex cystometrogram (51728), electromyography 
studies (51784), measurement of post-voiding residual urine (51798), complex uroflometry (51741) and 
voiding pressure studies (51797) provided November 27, 2019. 
 
You asked the Plan to pay for a complex cystometrogram, electromyography studies, measurement of post-
voiding residual urine, complex uroflometry and voiding pressure studies. You say that you would like 
reconsideration based on the medical records provided. The Plan denied your request. The Plan says the 
medical records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 complex cystometrogram, 
electromyography studies, measurement of post-voiding residual urine, complex uroflometry and voiding 
pressure studies. Our reviewer says that the billed services are not supported in this case. Our physician 
reviewer found documentation submitted was reviewed and does not meet criteria.  Documentation did not 
include a complete interpretation and report of CPT codes 51728, 51784, 51798, 51741 and 51797. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a complex cystometrogram, electromyography studies, measurement of post-
voiding residual urine, complex uroflometry and voiding pressure studies have not been met. Therefore, we 
decided that the Plan does not have to pay for a complex cystometrogram (51728), electromyography studies 
(51784), measurement of post-voiding residual urine (51798), complex uroflometry (51741) and voiding 
pressure studies (51797) provided November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided on February 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services that you provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from July 30, 2019, to July 31, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in Hospice when the services were provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided from July 30, 2019, to July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided  
January 13, 2020 to January 15, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $390 
copayment each day for days 1-5 for Medicare-covered hospital care.  
 
You have been asked to pay a $780 copayment ($390 x 2 days) for the inpatient hospital care provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. The record 
shows that you issued payment to the provider in the amount of $45. Therefore, your responsibility is $735 for 
the inpatient services. 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 copayment for the inpatient hospital care 
provided January 13, 2020 to January 15, 2020.  
 
Your complaint about your inpatient stay being extended due to the negligence of the hospital staff 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 pay for biologic materials to aid in tissue regeneration (D3431) 
provided on April 8, 2020. 
 
You asked the Plan to pay for biologic materials to aid in tissue regeneration (D3431). You say that you needed 
sedation in order to have the dental work. You say that anesthesia was best for your comfort and safety. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 biologic 
materials to aid in tissue regeneration (D3431) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 9, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5257) provided January 15, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says only hearing aids provided by contracted suppliers are covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased by network suppliers. 
 
We looked at the file and the Plan's rules. The hearing aids were supplied by an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) provided January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedures, resin-based 
composites and extractions provided on June 5, 2020 and June 10, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedures, resin-based composites and extractions. 
You say that these are necessary procedures to keep your teeth. You say that you used an in-network dentist 
and the charges should be lowered. The Plan denied your request. The Plan says the 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 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 the 
unspecified preventive procedures, resin-based composites and extractions provided on June 5, 2020 and June 
10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and limited oral evaluation provided on 
March 24, 2020. 
 
You asked the Plan to pay for the intraoral x-ray. You say that the dentist office will accept the discounted rate. 
You say that you have at least 50% coverage for out-of-network dental services. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
intraoral x-ray and limited oral evaluation provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy services (52240, 52005, 51720) provided 
September 13, 2019. 
 
You asked the Plan to pay for cystourethroscopy services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the denied codes remain not supported. 
 
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 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 cystourethroscopy services. Our reviewer 
says that the billed codes are not supported. Our physician reviewer found documentation submitted was 
reviewed, and does not met criteria.  Documentation did not include CPT 52240: Cystourethroscopy, with 
fulguration (including cryosurgery or laser surgery) and/or resection of; large bladder tumor(s), CPT 52005 and 
CPT 52240 is included in CPT 52240 and cannot be billed separately. Documentation did not support distinct 
or independent from the primary service billed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystourethroscopy services have not been met. Therefore, we decided that the 
Plan does not have to pay for cystourethroscopy services (52240, 52005, 51720) provided September 13, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services rendered on December 1, 2019 to 
December 31, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code T2046. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the hospice services rendered on December 1, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on 
November 12, 2019. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was 
medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate 
the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are medical 
records supporting medical necessity.  
 
Medical records supporting medical necessity for the orthosis were not submitted from the provider. Therefore, 
we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on 
November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2710) provided on March 10, 
2020. 
 
You asked the Plan to pay for the resin-based composite (D2710). You say that the covered amount should be 
re-evaluated. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the resin-
based composite (D2710) provided on March 10, 2020.  
 
Your complaint about unsatisfactory service 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 pay for the two resin-based composites of one surface (D2330 x2), 
resin-based composite of two surfaces (D2331), periodic oral evaluation (D0120), and bitewings (D0272) 
provided on February 19, 2020 and April 8, 2020 by an OON provider. 
 
You asked the Plan to pay for the resin-based composites, periodic oral evaluation, and bitewings. You say that 
your enrollment guide indicates that you have no deductible and a $0 copay for covered fillings, as well as 
preventive and diagnostic services, such as exams, x-rays, routine cleanings, and fluoride. The Plan denied 
your request. The Plan says resin-based composites are not a covered benefit under your dental plan. The Plan 
also says that the claim for the periodic oral evaluation and bitewings was processed and paid correctly, and the 
remaining amount is your responsibility. 
 
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, resin-based composites are not among 
those covered under this benefit. The contract also states that for services received OON, you are responsible 
for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not 
have to pay for the two resin-based composites of one surface (D2330 x2), resin-based composite of two 
surfaces (D2331), periodic oral evaluation (D0120), and bitewings (D0272) provided on February 19, 2020 and 
April 8, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 28, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on May 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 15, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that your regular dentist was 
closed. You say that you were informed that you should not delay treatment. The Plan denied your request. The 
Plan says the service exceeds the frequency limitation in benefit plan. 
 
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, you also have a maximum benefit of 
one limited oral evaluation per plan year. The Plan paid for a limited oral evaluation on March 30, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140) provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit (99213) and the x-ray exam 
of the ankle (73610) provided on March 12, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $75 
copayment for services obtained from an out of network specialist and a $40 copayment for each Medicare-
covered standard x-ray service provided.  
 
You have been asked to pay $107.13 (the allowed amount of $73.37 for the office visit and $33.76 for the x-ray 
exam) which are less than the applicable copayments for these services. 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 copayments for the office visit (99213) and the x-ray exam of the ankle (73610) provided on March 12, 
2020.