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

 
We decided that the Plan has to pay for complete series dental x-rays (code D0210) provided on March 17, 
2022. 
 
You asked the Plan to pay for the dental x-rays. You say that you will not go to this provider again and make 
sure that the next provider is approved. The Plan denied your request. The Plan says that your benefit for the 
requested item or service has already been 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. The Plan has failed to provide any claims or documentation showing that it has paid for complete 
series dental x-rays for you within the past 5 years. Therefore, we decided that the Plan has to pay for complete 
series dental x-rays (code D0210) provided on March 17, 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: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on May 17, 2022, endodontic therapy on tooth #5 (D3320) and a resin-based composite 
filling on tooth #5 (D2391) provided on May 24, 2022, and resin-based composite filling on tooth #3 (D2392) 
provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on May 17, 2022, 
endodontic therapy on tooth #5 (D3320) and a resin-based composite filling on tooth #5 (D2391) provided on 
May 24, 2022, and resin-based composite filling on tooth #3 (D2392) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan is not covering the oral evaluation to 
re-cement and re-bond the crown. You say that you are required to be evaluated for where the crown is to be 
re-cemented. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the raised toilet seat (code E0244) you purchased on January 
29, 2022. 
 
You asked the Plan to pay for the raised toilet seat. You say that this item was needed following a 
hospitalization. The Plan denied your request. The Plan says you did not used a Medicare-certified provider, so 
this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the raised toilet seat (code E0244) you 
purchased on January 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the limited oral evaluation-problem focused (D0140) provided on  
May 24, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that this service is 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.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have been met. Specifically, the Plan contract states that this service is a covered 
benefit only when performed by an oral surgeon. The limited oral evaluation in this case was performed by an 
oral surgeon. Therefore, we decided that the Plan has to pay for the limited oral evaluation-problem focused 
(D0140) provided on May 24, 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: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe 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 the requested item or service was exhausted on date of service April 21, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by 
a participating provider on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 3, 2022, by 
an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 a domiciliary or rest home visit provided on May 
3, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp vitality test on tooth #19 (D0460) provided on April 
28, 2022. 
 
You asked the Plan to pay for a vitality test. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a pulp vitality test (D0460) 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 pay for a pulp 
vitality test on tooth #19 (D0460) provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided by an out-of-network provider on January 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that these should be covered because these are basic 
services. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 bitewings (D0274), periodic oral evaluation (D0120), and prophylaxis (D1110), provided by an out-
of-network provider on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission. 
 
You asked the Plan to pay for an inpatient hospital admission. You say that the records provided support the 
need for an inpatient hospital admission. The Plan denied your request. The Plan says the current medical 
standard guidelines indicate that this minimally invasive procedure is performed on an outpatient basis with the 
expectation that the procedure will only keep the enrollee in the hospital for less than 24-hours. The Plan says 
that the enrollee does not have any high-risk indications that indicate an inpatient admission would be needed. 
The Plan says that the request for an inpatient admission prior to the operation being completed is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the knee arthroplasty procedure may be safely performed with an 
observational 48-hour stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pay for an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided January 10, 
2022. 
 
You asked the Plan to pay for the porcelain/ceramic crown. You say that you do not understand why this is 
denied. The Plan denied your request. The Plan says benefits have been paid on the least costly method of 
treatment, and you will be responsible for the remaining balance 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
porcelain/ceramic crown with 50% coinsurance after the $100 deductible is met. The Plan contract also says 
that when there is an alternate, less expensive procedure, the allowed amount will be the charge for the less 
expensive treatment.  
 
We looked at the file and Medicare rules. In this case you have been asked to pay the $100 deductible plus 50% of the allowed amount for the procedure. You are also responsible for the difference between the allowed 
amount and the dentists total charge for a more costly procedure. This means you have been asked to pay the 
correct amount based on your contract with the Plan.  Therefore, we decided that the Plan does not have to pay 
for the crown - porcelain/ceramic (D2740) provided January 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional home health physical therapy (PT) 
services (G0151). 
 
You asked the Plan to pre-approve the home health PT visits. You say that the enrollee has not met goals and is 
debilitated due to chronic diagnosis. The Plan denied your request. The Plan says the medical necessity for the 
additional PT visits has not been established. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the home health PT visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical documentation shows that enrollee does have functional impairments that 
would require the skill of a professional therapist however there is no documentation to show why the enrollee 
would be considered home bound. Therapy notes state that the enrollee is able to ambulate 150ft with rolling 
walker which is typically considered a "community level distance" thus 10 additional home health PT visits are 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 additional home health physical therapy (PT) services (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an impacted tooth removal (D7230) provided by a 
participating provider on June 7, 2022. 
 
You asked the Plan to pay for an impacted tooth removal. You say that you do not understand why this is not 
covered. The Plan denied your request. The Plan says the rendered dental work 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 an 
impacted tooth removal (D7230) provided by a participating provider on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 7, 2021 billed 
with codes 81226, 81225, 81335, 81230, 81241, 81291, 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you formally request the claim to be 
reprocessed along with the enclosed medical records. The Plan denied your request. The Plan says does not 
meet Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 7, 2021 billed with codes 81226, 81225, 81335, 81230, 81241, 81291, 81240.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve 3 additional visits. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because 
the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 additional visits. Our reviewer says 
that the requested services are not medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document any acute or unstable medical conditions or changes in 
medication or treatment which would necessitate any further skilled nursing visits beyond what has already 
been approved. Records document you or your caregiver have been educated on disease process and 
medications. No medical notes from your treating physician are provided documenting an order or need for 
additional skilled nursing services beyond what has been approved. Records do not document the need for 
intravenous medications, new tube feeding or ostomy care, or daily complex wound care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3 additional home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation on February 28, 2022. 
 
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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation on February 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 laboratory services provided on June 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
April 26, 2022. 
 
You asked the Plan to pay for procedure codes 99140 and 99100. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 99140 an 99100 are 
considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99140 and 99100 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99140 and 99100 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99140 and 99100 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
April 26, 2022.