Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), mechanical 
traction therapy (97012), and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider 
on January 4, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the chiropractic manipulative treatment (98941), mechanical traction therapy 
(97012), and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider on January 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, endosteal implant, bone 
replacement graft, inhalation of nitrous oxide/analgesia, and non-intravenous conscious sedation (D7953, 
D6010, D4266, D9230, D9248) provided on September 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your Plan benefits. Coverage may be provided by your former employer/union/trust. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for guided tissue regeneration, 
endosteal implant, bone replacement graft, inhalation of nitrous oxide/analgesia, and non-intravenous 
conscious sedation (D7953, D6010, D4266, D9230, D9248) provided on September 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lidocaine pad 5%. 
 
You asked the Plan to pre-approve a Lidocaine pad 5%. You say that this should be covered. The Plan denied 
your request. The Plan says self-administered drugs are not a covered 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 pre-approve a Lidocaine pad 5%.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 1, 
2022. 
 You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 99204. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 
is a column II code to column I code 99204. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 1, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services (codes 97802 and 
97803) provided from May 9, 2022, to September 20, 2022. 
 
You asked the Plan to pay for the medical nutrition therapy services. The Plan denied your request. The Plan 
says medical nutrition therapy is covered by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
 
 
 
 
 The provided records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we 
decided that the Plan does not have to pay for the medical nutrition therapy services (codes 97802 and 97803) 
provided from May 9, 2022, to September 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78815 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 78815. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 78815 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 78815 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 78815 billed for date of service July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the anti-glare coating, the impact-resistant lenses, and 
the UV protection provided on November 7, 2022. 
 You asked the Plan to pre-approve the anti-glare coating, the impact-resistant lenses, and the UV protection. 
You say that your provider recommended the enhancements, and you want them covered. The Plan denied your 
request. The Plan says the enhancements are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard lenses and frames. 
 
We looked at the file and the Plan's rules. Specifically, the anti-glare coating, the impact-resistant lenses, and 
UV protection are considered enhancements. Based on this information, we decided that the Plan's rules for 
coverage of the anti-glare coating, the impact-resistant lenses, and the UV protection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the anti-glare coating, the impact-resistant 
lenses, and the UV protection provided on November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for inpatient hospital services provided on October 13, 
2022, through October 16, 2022. 
 
You asked the Plan to hold you harmless for the inpatient hospital services. You say that you were on vacation 
and had a gallbladder attack. You say that you went to the emergency room and were admitted for emergency 
surgery. You say that the doctor had delays and the surgery was pushed back a day. The Plan denied your 
request. The Plan says that the procedure is not an inpatient procedure, and the documentation did not show 
any surgical complications or comorbidities requiring an acute inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to hold you harmless for 
inpatient hospital services provided on October 13, 2022, through October 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Sensor. You say that this is a medical necessity. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits.  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G6 Sensor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza 8% topical system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Type 2 diabetes with 
diabetic polyneuropathy. She has not tried and failed the Plan's required drug, at least one tricyclic 
antidepressant. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Qutenza 8% is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Qutenza 8% topical system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cuvitru. 
 
You asked the Plan to pre-approve Cuvitru. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Cuvitru.  
 
  Benefits for Cuvitru 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 the problem focused limited oral evaluation and panoramic 
x-ray provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were needed to assess whether 
you are a candidate for a dental implant. 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 items or services was exhausted on date of service August 30, 2022, and 
September 13, 2022. Therefore, we decided that the Plan does not have to pay for the problem focused limited 
oral evaluation and panoramic x-ray provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) and pay more for a consultation 
(D9310) provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider told you that your services were 
covered at 100% and you did not know you reached your maximum. The Plan denied your request. The Plan 
says your annual dental maximum benefit for the year 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. On February 
3, 2022, the Plan paid $65 for dental services. On March 16, 2022, the Plan paid $657 for dental services. On 
March 24, 2022, the Plan paid $657 for dental services. On May 25, 2022, the Plan paid $357 for dental 
services. On June 8, 2022, the Plan paid $672 for dental services. On August 11, 2022, the Plan paid $284 for 
dental services. On August 18, 2022, the Plan paid $84 for dental services. On November 17, 2022, which was 
processed prior to November 10, 2022, the Plan paid $68 for dental services. On November 10, 2022, the Plan 
paid $56 for dental services. For the year of 2022 the Plan paid $2,900 ($65 paid + $657 paid + $657 paid + 
$357 paid + $672 paid + $284 paid + $84 paid + $68 paid + $56 paid) for dental services. Therefore, the annual 
dental maximum for the year of 2022 was exhausted on the date of service of November 10, 2022. Therefore, 
we decided that the Plan does not have to pay for a cone beam (D0364) and pay more for a consultation 
(D9310) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was not in-
network with the Plan anymore. 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 the periodic oral evaluation and prophylaxis provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and four units of local anesthesia 
provided from November 4, 2022, to November 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay this claim. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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, local anesthesia is not among those 
covered under this benefit. Additionally, the Plan paid for a comprehensive evaluation on September 24, 2021, 
exhausting your benefit for this service. The Plan applied and paid for an alternative benefit, a periodic 
evaluation leaving you with a $5 balance for the evaluation. Therefore, we decided that the Plan does not have 
to pay for the remaining balance of a periodic oral evaluation and four units of local anesthesia provided from 
November 4, 2022, to November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical extraction (D7210) provided on November 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider was in-network, but you were not 
aware that the office where the extraction was performed was out-of-network. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted and the cost sharing 
was correctly applied. 
 
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 D0140 was exhausted on date of service March 07, 2022. Additionally, the cost sharing 
for an out-of-network extraction was processed correctly. Therefore, we decided that the Plan does not have to 
pay for the problem focused limited oral evaluation (D0140) and surgical extraction (D7210) provided on 
November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) and prophylaxis  adult 
(D1110) provided on November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you needed an authorization 
for your dental visit. 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 periodic oral evaluation (D0120) and prophylaxis  adult (D1110) provided on November 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
October 6, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the enrollee was 
unaware there would be a copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each outpatient surgery.  
 
 The enrollee has been asked to pay a $225 copayment for a diagnostic colonoscopy. This item/service falls 
within the outpatient surgery, including services provided at ambulatory surgical centers benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on October 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on October 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that the doctor visit was an emergency, and the 
dentist determined the bitewings were necessary. 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 February 24, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
limited oral evaluation - problem focused (D0140), and extraction, erupted tooth or exposed root (D7140) 
provided on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were needed due to an emergency 
and no in-network provider could get you in immediately. 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 an intraoral - periapical first radiographic image 
(D0220), limited oral evaluation - problem focused (D0140), and extraction, erupted tooth or exposed root 
(D7140) provided on August 9, 2022.