Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on June 30, 2021. 
 
You asked the Plan to pay for critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the enrollee had another insurance provider as the primary insurer on 
the date in question. An explanation of benefits from this insurer is necessary to process this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for critical 
care services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for critical care (99291) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on May 17, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you were 
assured that records were sent from your previous dentist. You also say if those records had been checked prior 
to your visit, the dentist would have seen that the bitewing x-rays and panoramic x-ray did not need to be 
repeated. 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 August 10, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) provided on May 17, 2022.
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 26, 
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 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option, long leg rests, and posture control belt 
for a power wheelchair. 
 You asked the Plan to pre-approve a transit option, long leg rests, and posture control belt. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested transit option at issue in this appeal is for the power wheelchairs use outside of the home. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.  
The requested leg rests are being requested under code K0108. Code K0108 is the incorrect code for legrests. 
K0108 cannot be used for legrests, as they have their own correct code. This means these items are not a 
covered benefit. Review of the file shows that a seat belt is already included with the power wheelchair. This 
means the requested belt is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve a transit option, long leg rests, and posture control belt for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) provided on April 15, 
2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that the back of a crown broke, and a tooth 
was removed. You also say that a graft or space was used to close the spot the tooth was located, and you 
would like part of the cost to be paid. 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, 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 bone 
replacement graft (D4263) provided on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator.. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in 
this way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable ventilator. have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and osseous surgery (D4261) provided on February 14, 2022. 
 
You asked the Plan to pay for biologic materials to aid in soft and osseous tissue regeneration (D4265) and 
osseous surgery (D4261). You say that the EOC, on page 73, lists periodontics services as covered services and 
further states that the Plan pays up to $2,000 every year for non-Medicare covered preventive and 
comprehensive dental services. You also say you cannot understand how they procedures are not covered under 
your plan. The Plan denied your request. The Plan says this 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, 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 soft and osseous tissue regeneration (D4265) and osseous surgery (D4261) provided on 
February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body on tooth # 12 and 13 
(D6011). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says surgical access to an implant body (D6011) 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 pre-approve 
surgical access to an implant body on tooth # 12 and 13 (D6011).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on September 
15, 2021. 
 
You asked the Plan to pay for the testing services. You say that the documents support the codes. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 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 find that a single CPT code was not billed as required. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the pharmacogenomics panel testing provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system, manual swing away, and power 
lateral tilt lockout electronics. 
 You asked the Plan to pre-approve a seat elevation system, manual swing away, and power lateral tilt lockout 
electronics. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is specifically not 
covered. The documentation shows that the enrollee is dependent for all transfers and transitions. This means 
the enrollee does not meet criteria for the requested swing away. The documentation shows that the requested 
electronics is only requested to accompany the seat elevation system. The seat elevation system is not a 
covered benefit; therefore, the requested accessory for the seat elevation system is not covered. Based on this 
information, we decided that Medicare rules for coverage of a seat elevation system, manual swing away, and 
power lateral tilt lockout electronics have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a seat elevation system, manual swing away, and power lateral tilt lockout electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), extraction of an erupted 
tooth or exposed root (D7140), comprehensive oral evaluation (D0150), dental cleaning (D1110), and the 
intraoral-complete series of radiographic images (D0210) provided from February 21, 2022, through April 4, 
2022. 
 
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 these services are not payable as they were 
rendered by an out-of-network provider. Additionally, a limited oral evaluation is not covered 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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, a limited oral evaluation is not among 
those covered under this benefit. Additionally, the Plan contract states that services rendered by an  
out-of-network provider are not covered. The services in this case were rendered by an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), 
extraction of an erupted tooth or exposed root (D7140), comprehensive oral evaluation (D0150), dental 
cleaning (D1110), and the intraoral-complete series of radiographic images (D0210) provided from  
February 21, 2022, through April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 14, 
2022. 
 You asked the Plan to pay for procedure code 99100. You say that the claim at issue was billed correctly. The 
Plan denied your request. The Plan says procedure code 99100 is 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ipilimumab and nivolumab. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 ipilimumab and nivolumab are not 
Food and Drug Administration (FDA)-approved for the treatment of Merkel cell carcinoma. The combination 
is not supported by major drug compendia or the medical literature and is not found in the National 
Comprehensive Cancer Network (NCCN) guidelines for Merkel cell cancers. The service 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 ipilimumab and nivolumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete 
intraoral series of radiographic images (D0210), and an intraoral periapical radiographic image (D0230) 
provided from March 17, 2022, through April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network and 
these services should be covered. The Plan denied your request. The Plan says your benefit for the requested 
services have 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 and the complete intraoral series of radiographic 
images was exhausted on date of service July 21, 2022. The record shows your benefit for the intraoral 
periapical radiographic image was exhausted on date of service March 17, 2022. Therefore, we decided that the 
Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete intraoral series of 
radiographic images (D0210), and an intraoral periapical radiographic image (D0230) provided from March 17, 
2022, through April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant (D6010) provided on May 11, 2022. 
 
You asked the Plan to pay for an implant. You say that you were eating candy and your tooth broke. The Plan 
denied your request. The Plan says a dental implant (D6010) is not covered by your dental 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 a dental 
implant (D6010) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a panoramic 
radiographic image (D0330), and a complete upper denture (D5110) provided on March 31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that the provider was 
out-of-network. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
 
 
 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation (D0150), a 
panoramic radiographic image (D0330), and a complete upper denture (D5110) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you have been dealing with this since April 
2021 and you received temporary dentures at that time; however, they never fit correctly even after several 
realignment attempts by the provider. In addition, you returned the dentures to the provider in June 2022, and 
was told a reinstatement request could be submitted so you could receive dentures from a different provider. 
You also say you currently cannot eat anything more than baby food and have lost a lot of weight due to not 
being able to eat solid foods. 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 August 3, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) and the core 
buildup, including any pins when required (D2950) provided on March 17, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, these dental items are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full cast high noble 
metal crown (D2790) and the core buildup, including any pins when required (D2950) provided on March 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy of premolar and anterior teeth 
(D3320, D3310), two core buildups (D2950) and two porcelain or ceramic crowns (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that during your visit to the dentist, you had a 
tooth extracted which made the prosthesis fit improperly. The Plan denied your request. The Plan says the 
requested procedures are 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 codes (D3320, D3310, 
D2950, and D2740) are not among those listed in the 2022 Dental Benefit Schedule DEN834. This means the 
requested services are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy of premolar and anterior 
teeth (D3320, D3310), two core buildups (D2950) and two porcelain or ceramic crowns (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5225) provided by a network 
provider on February 22, 2022. 
 
You asked the Plan to pay for the upper partial denture (D5225). You say that it was your understanding that 
50% would be covered by the dental insurance. 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 upper partial denture (D5225) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
upper partial denture (D5225) provided by a network provider on February 22, 2022.