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

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on July 28, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010), prefabricated abutments 
(D6056), custom fabricated abutments (D6057), removal of benign odontogenic cyst or tumor (D7450), and 
bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, custom fabricated 
abutments, removal of benign odontogenic cyst or tumor, and bone replacement graft. You say that you feel 
dentures will not be beneficial for you. You also say these services are medically necessary for your ongoing 
health. The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010), prefabricated abutments (D6056), custom fabricated abutments (D6057), removal 
of benign odontogenic cyst or tumor (D7450), and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
March 22, 2021. 
 
You asked the Plan to pay for periodontal scaling. You say that you disagree with the denial of payment for 
dental services. The Plan denied your request. The Plan says your annual maximum amount for dental services 
has been exhausted. 
 
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 the Plan covers up to a 
$2,000 annual maximum for dental services. The contract says that once the annual maximum is exhausted the 
enrollee is responsible for any remaining charges. 
 
The record shows your annual maximum has been exhausted and you are responsible for the charges. 
Periodontal scaling falls within the Dental Services 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 pay for 
periodontal scaling and root planing (D4341) provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
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 
October 12, 2021 billed with codes 81206 and 81292.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray provided on February 2, 2021. 
 
You asked the Plan to pay for the office visit and x-ray. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit and x-ray provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 22, 2022. 
 
You asked the Plan to pay for a consultation. You say that you cannot believe your insurance will not cover a 
consultation. The Plan denied your request. The Plan says a consultation (D9310) is not covered by your 
routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) and crown (D2752) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
you were covered to see your endodontist after the services were authorized. You say that you were advised the 
crown would be covered at 50%. You also say that you should be reimbursed the 50% cost share. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and 
therefore are not covered by your supplemental benefits. The Plan also says that prior authorization was not 
requested for any services or providers other than a root canal. 
 
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 prophylaxis and crown 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 prophylaxis (D1110) and crown (D2752) provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on April 13, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364), a crown (D2740), prefabricated 
post (D2954), endodontic therapy (D3320), and intraoral x-rays (D0210) provided on January 3, 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 cone beam imaging (D0364), a crown (D2740), prefabricated post 
(D2954), and endodontic therapy (D3320) are not covered by your routine dental benefits. The Plan also says 
that your benefit for intraoral x-rays has 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, cone beam imaging, crowns, 
prefabricated posts, and endodontic therapy are not among those covered under this benefit. The record shows 
the Plan paid for intraoral x-rays on date of service December 8, 2020; your benefit for intraoral x-rays has 
been exhausted. Therefore, we decided that the Plan does not have to pay for cone beam imaging (D0364), a 
crown (D2740), prefabricated post (D2954), endodontic therapy (D3320), and intraoral x-rays (D0210) 
provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on April 11, 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided to the enrollee from November 1, 
2021, to November 3, 2021. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says no medical records were submitted by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the supplies provided to the enrollee 
have been met. The provider did not submit any medical records to verify the coding of this claim. Therefore, we decided that the Plan does not have to pay for the supplies provided to the enrollee from November 1, 2021, 
to November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite - two surfaces, posterior 
(D2392). 
 
You asked the Plan to pre-approve a filling. You say that the enrollee needs this service. 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 18, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a resin-based composite - two surfaces, 
posterior (D2392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment  includes modification and placement (D6056), and abutment supported 
porcelain fused to metal crown (high noble metal) (D6059). 
 
You asked the Plan to pre-approve an endosteal implant, prefabricated abutment and abutment supported 
crown. You say that you need these services to eat normally. The Plan denied your request. The Plan says these 
services are not covered under your 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 a surgical placement of implant body: endosteal implant (D6010), prefabricated abutment  includes 
modification and placement (D6056), and abutment supported porcelain fused to metal crown (high noble 
metal) (D6059).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided December 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 CPT code 87150 is not supported in the medical record. Specifically, the records did not include 
results for cultures and typing by nucleic acid probe. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (87150) provided December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 27, 2022, through January 31, 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 that the services provided are not payable as prior authorization was not issued.

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. Additionally, the rules say that a Medicare Plan is financially responsible for emergency services regardless of whether the services are obtained within or outside the Plan. Emergency services are covered whether there is prior authorization for the services. An emergency is defined as when a person would believe that without immediate medical attention there would be serious jeopardy to his or her health.  

We decided that this case does meet the prudent layperson criteria for emergency care. A prudent layperson would reasonably expect that the absence of immediate medical care would seriously jeopardize their health. 
In this case, you sought care in the emergency department due to chest pains and were admitted as an inpatient in the hospital. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to provide an argument as to why this emergency care should not be covered beyond the unapplicable prior authorization rationale indicated. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 27, 2022, through January 31, 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 comprehensive oral exam (D0150) and panoramic x-ray 
(D0330) provided on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. The Plan also states that although the comprehensive exam was denied under your Medicare 
benefit, the exam has been covered by your Medicaid 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, certain limitations apply. The record 
shows your benefits for the requested services were exhausted on date of service February 9, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray 
(D0330) provided on March 31, 2022, under your Medicare benefit. Please note that the Plan has indicated that 
the comprehensive oral exam (D0150) has been paid under your Medicaid benefit, and we do not have 
jurisdiction regarding Medicaid benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an implant supported crown. You say that this dental work is necessary to 
avoid further issues. The Plan denied your request. The Plan says dental implants are not covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. 
 
Therefore, we decided that the Plan does not have to pre-approve an implant supported crown (D6065) 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided on March 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have dental coverage. You also say that this 
service should be covered by a dental plan. The Plan denied your request. The Plan says extraction is not listed 
as a covered service. 
 
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 extraction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) 
provided on March 10, 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 March 
15, 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 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 3, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Benralizumab injection provided on 
February 22, 2022. 
 
You asked the Plan to waive the coinsurance for a Benralizumab injection. You say that you were not aware 
there would be a coinsurance attached to this visit. The Plan denied your request. The Plan says the coinsurance 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $5883.08 resulting in a 
coinsurance amount of $1176.42. ($5883.08 x 20% = $1176.42) 
 
You have been asked to pay a 20% coinsurance for a Benralizumab injection. a Benralizumab injection falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for a Benralizumab injection provided on February 22, 2022.  Your complaint about not knowing or being told about the 20% coinsurance amount is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.