Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option (K0108) and air tire inserts (E2213). 
 
You asked the Plan to pre-approve a transit option and air tire inserts. You say that the requested transit option 
(K0108) and air tire inserts (E2213) are medically necessary. The Plan denied your request. The Plan says the requested transit option (K0108) is not covered by Medicare or the Plan and the requested air tire inserts 
(E2213) are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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 air tire 
inserts. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is with a medical history of cerebral palsy and 
seizure disorder. The enrollee is non-ambulatory and requires a manual wheelchair for mobility. He is 
dependent or requires maximum assistance for his daily activities. A wheelchair and seating evaluation was 
performed on August 16, 2022, which indicated that the enrollee is unable to propel a manual wheelchair and it 
would be propelled by his caregiver. The enrollee requires a tilt in space manual wheelchair given his inability 
to independently perform pressure relief and sacral pressure sore.  
 
The enrollee is non-ambulatory and requires a manual wheelchair for mobility. He is dependent or requires 
maximum assistance for his daily activities and cannot propel a manual wheelchair. The enrollee does not 
require pneumatic tires or air tire inserts given that this is primarily a convenience item and not essential to the 
functioning of the manual wheelchair. They exceed the needs of the enrollee. These are typically used in 
patients who can propel a manual wheelchair and require decreased resistance with propulsion or when 
operating the wheelchair consistently on uneven terrain. Therefore, the manual wheelchair air tire inserts 
(E2213) are not medically necessary. 
 
Medicare rules also say that for equipment to be covered, it must be appropriate and needed for use inside the 
home. The transit option at issue in this appeal is for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
 
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 transit option and air tire inserts have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a transit option (K0108) and air tire inserts (E2213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 3, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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). Your contract with the Plan clearly says that you must pay $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $34.26 copayment which is less than the $35 copayment for office visit. This 
item/service falls within the physician/practitioner services, including doctor's office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for office visit provided on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310). 
 
You asked the Plan to pre-approve a consultation. You say that this is an emergency because you are unable to 
eat, and cannot do anything. 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 September 19, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions (D7140) provided by an out-of-network 
provider on May 24, 2022. 
 
You asked the Plan to pay for dental extractions. You say that you needed the extractions in order to get 
dentures fabricated. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 dental 
extractions limited to trauma/accident to the jaw or in preparation for radiation due to malignancy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental extractions have not been met. Therefore, we decided that the Plan does not have to pay for 
dental extractions (D7140) provided by an out-of-network provider on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you have provided medical records to 
support payment for this service. 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 99291 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network referral for cardiology. 
 
You asked the Plan to pay for the referral. You say that you have been this provider's patient for many years. 
The Plan denied your request. The Plan says this is an out-of-network provider.  
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 the referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found that there are 
credentialed, experienced physicians within the patient's network who could be utilized for the patient's clinical 
condition. In summary, there is insufficient documentation to support the medical necessity for referral to an 
out-of-network provider for the patient's management. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pay for an out-of-network referral for cardiology.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740), core buildup (D2950), and extended 
care facility call (D9410) for tooth #7, #8, and #9 provided on April 19, 2022, and May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your annual dental benefit 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 annual dental benefit was exhausted on the date of service of May 12, 2022. On March 21, 2022, 
the Plan paid $556 for the dental services. On March 22, 2022, the Plan paid $1,009 for the dental services. On 
May 3, 2022, the Plan paid $2,933 for the dental services. On May 12, 2022, the Plan paid $502 towards the 
dental services. On May 12, 2022, the total amount the Plan paid for the yearly dental services was $5,000 
($556 paid + $1,009 paid + $2,933 paid + $502 paid). Therefore, we decided that the Plan does not have to pay 
for the crowns (D2740), core buildup (D2950), and extended care facility call (D9410) for tooth #7, #8, and #9 
provided on April 19, 2022, and May 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 78815 billed for date of service January 4, 2022. 
 
You asked the Plan to pay for code 78815. You say that this code is not bundled with any other service. The 
Plan denied your request. The Plan says payment for code 78815 is bundled into payment for code 78816. 
 
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 78815 
is a column II code to column I code 78816 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 78815 billed for date of service January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic 
images (D0274), topical application of fluoride (D1206), periodontal maintenance (D4910), and a filling 
(D2391) provided from May 7, 2021, through September 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the claims for dates of service May 7, 2021, and June 4, 2021, were 
received on June 15, 2022. This is past the allowed 12-month timeframe. Topical application of fluoride and 
periodontal maintenance services that were received on September 29, 2021, are not covered benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The rules say that claims for 
services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of 
service. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the topical application of fluoride and 
periodontal maintenance provided on September 29, 2021, are not among those covered under this benefit. 
Additionally, the record shows that a claim for dates of service May 7, 2021, and June 4, 2021, were not filed 
until June 15, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), bitewing radiographic images (D0274), topical application of fluoride (D1206), periodontal 
maintenance (D4910), and a filling (D2391) provided from May 7, 2021, through September 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 16, 2021, to October 1, 2021 
 
You asked the Plan to pay for SNF care. You say that you are appealing the denied SNF care. The Plan denied 
your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met and the 
enrollee exhausted all 100 days. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
  The file shows that the enrollee received 100 days of SNF care during the benefit period from June 8, 2021, to 
September 15, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from September 16, 
2021, to October 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), prophylaxis (D1110), and a periodic oral 
evaluation (D0120), provided by an out-of-network provider on January 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told after the services were provided 
that they were not covered. 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), prophylaxis (D1110), and a periodic oral evaluation (D0120), provided by an 
out-of-network provider on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on August 8, 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 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 tooth 
extraction (D7210) provided on August 8, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you changed providers and the service was 
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 date of service February 23, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on July 5, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test (D0431). You say that you are aware of the 
charge for the adjunctive pre-diagnostic test for mucosal abnormalities and have paid for that. The Plan denied 
your request. The Plan says this service is not covered under the benefit package.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431). The Plan agreed to pay for the 
intraoral - complete series of radiographic images (D0210), and topical application of fluoride varnish (D1206)  
provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0150), the intraoral radiographic 
images (D0210), the panoramic image (D0330), facial photographic images (D0350), the fluoride varnish 
(D1206), oral hygiene instructions (D1330), the core buildup (D2950), scaling and root planning (D4341), the 
gingival irrigation (D4921), and the periodontal procedure (D4999) for tooth #30 provided on June 15, 2022, 
and June 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
services. 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 comprehensive oral evaluation, the complete series of radiographic images, and 
panoramic images was exhausted on the date of service of August 12, 2021. The facial photographic images, 
the fluoride varnish, oral hygiene instructions, the core buildup, scaling and root planning, the gingival 
irrigation, and the periodontal procedure are not covered under the Plans dental benefits. Therefore, we decided 
that the Plan does not have to pay for the oral evaluation (D0150), the intraoral radiographic images (D0210), 
the panoramic image (D0330), facial photographic images (D0350), the fluoride varnish (D1206), oral hygiene 
instructions (D1330), the core buildup (D2950), scaling and root planning (D4341), the gingival irrigation 
(D4921), and the periodontal procedure (D4999) for tooth #30 provided on June 15, 2022, and June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4595), provide on June 8, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the enrollee's treating physician confirmed they did not order this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the electrodes (A4595), provide on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230), facial 
photographic images (D0350), cone beam (D0367), and oral hygiene instructions (D1330) provided on July 18, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you did not ask for the additional dental 
services. The Plan denied your request. The Plan says your benefit for the intraoral radiographic image has 
already been exhausted. Also, the denial of payment for the facial photographic images, cone beam, and oral 
hygiene instructions is correct, because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral radiographic images was exhausted on the date of service of July 18, 2022. 
The facial photographic images, cone beam, and oral hygiene instructions are not covered under the dental 
benefits. Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images 
(D0230), facial photographic images (D0350), cone beam (D0367), and oral hygiene instructions (D1330) 
provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the services were consistent with generally 
accepted principles of practice. The Plan denied your request. The Plan says payment for code 99497 is 
bundled into payment for code 99223. 
 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 99497 is a column II code to column I code 99223. 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 99497 
billed for date of service March 11, 2022.