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

 
We decided that the Plan does not have to pay for a diagnostic service consultation on March 4, 2022. 
 
You asked the Plan to pay for a diagnostic service consultation. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service in question is not 
covered under the member's contract under any normal circumstances. 
 
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 
diagnostic service consultation on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug, single administration 
(D9610) and the placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization, per 
site (D7922 x 2). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items/services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items/services are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve 
a therapeutic parenteral drug, single administration (D9610) and the placement of an intra-socket biological 
dressing to aid in hemostasis or clot stabilization, per site (D7922 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests received on January 11, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you feel you should be reimbursed because 
you got an email saying that it would be covered if you showed proof of payment. The Plan denied your 
request. The Plan says the items received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that starting January 15, 2022, most people with a 
health plan can go online, or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 
diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost, either through 
reimbursement or free of charge through their insurance. 
 
We looked at the file and Medicare rules. Review of the file shows that you received the tests on January 11, 
2022. The Plan benefits for COVID-19 testing kits went into effect on February 1, 2022. This means you 
received the test kits before the coverage went into effect. Based on this information, we decided that Medicare 
rules for coverage of the COVID-19 tests have not been met. Therefore, we decided that the Plan does not have 
to pay for the COVID-19 tests received on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from February 3, 2022, through 
March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by the supplemental 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. 
 
The record shows the enrollee 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 dental services provided from February 3, 2022, through March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supply 
allowance provided on November 2, 2021 and January 1, 2022. 
 You asked the Plan to pay for the therapeutic CGM supply allowance. You say that you disagree with this 
denial. The Plan denied your request. The Plan says the date of service and proof of delivery dates do not 
match. 
 
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 proof of delivery. Review of the file shows that the items were shipped on 
December 23, 2021 and delivered on December 28, 2021. This means the claim date of service does not match 
the proof of delivery date. 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 therapeutic 
continuous glucose monitor (CGM) supply allowance provided on November 2, 2021 and January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments-includes modification and 
placement (D6056 x 28). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutments-includes modification and placement (D6056 x 28).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on February 3, 2022. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the medical records attached 
support the services rendered, and the claim should be reconsidered for payment. The Plan denied your request. 
The Plan says CPT code 76377 has been overturned. The Plan also says CPT code 99153 may not be paid if 
furnished to hospital inpatients or patients in a hospital outpatient department. 
 
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, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership. 
 
You asked the Plan to pay for the gym membership. You say that you were  not made aware that by receiving 
that kit you would lose out on the gym membership payment. You say that you want to dispute the kit and get 
the insurance converge for the gym back. The Plan denied your request. The Plan says members who elect a 
home fitness kit will not be eligible to request for fitness reimbursement the month they requested a home 
fitness kit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when a home fitness kit is not purchased in the same month. 
 
 
  The Plans rules for coverage of gym benefits have not been met because a home fitness kit was ordered the 
same month reimbursement for a gym membership is being requested. Therefore, we decided that the Plan does 
not have to pay for the gym membership.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93621 billed for date of service March 15, 2021. 
 
You asked the Plan to pay for procedure code 93621. You say that these services were billed appropriately. The 
Plan denied your request. The Plan says they have agreed to cover most of the billed services; however, 
payment for code 93621 is bundled into payment for code 93656. 
 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 93621 
is a column II code to column I code 93656 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 procedure code 93621 billed for date of service March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nitrous oxide inhalation (D9230) and a surgical extraction 
(D7210), provided by an out-of-network provider on April 11, 2022. 
 
You asked the Plan to pay for nitrous oxide inhalation and a surgical extraction. You say that extractions 
should be covered. 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 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 nitrous 
oxide inhalation (D9230) and a surgical extraction (D7210), provided by an out-of-network provider on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health visit provided on March 1, 
2022. 
 
You asked the Plan to waive the copayment for a mental health visit. You say that the copayment amount is 
incorrect. The Plan denied your request. The Plan says the copayment 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 $40 
copayment for in-network outpatient mental health care.  
 
You have been asked to pay a $40 copayment for a mental health visit. A mental health visit falls within the In-
Network Outpatient Mental Health Care 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 a mental health visit provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgical extraction (D7210) and does not 
have to pay for alveoplasty (D7310), and a lower partial denture (D5214) provided on April 5, 2022. 
 
You asked the Plan to waive the coinsurance for an extraction and to pay for alveoplasty and dentures. You say 
that you were told these services were covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan also says that alveoplasty (D7310) and a lower partial 
denture (D5214) are not covered by your dental benefits. 
 
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 50% 
coinsurance for a surgical extraction.  
 
You have been asked to pay $41.50, which is 50% coinsurance of the allowed amount for an extraction ($83 
allowed amount x 50% coinsurance = $41.50). An extraction 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.  
 
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, alveoplasty and lower partial dentures 
are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to waive the 
coinsurance for a surgical extraction (D7210) and does not have to pay for alveoplasty (D7310), and a lower 
partial denture (D5214) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided by an 
out-of-network provider on January 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 maximum benefit allowance was met on January 13, 2022. Therefore, we decided that the Plan 
does not have to pay for an unspecified adjunctive procedure (D9999) provided by an out-of-network provider 
on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on March 23, 2022. 
 
You asked the Plan to pay for a guard. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says an occlusal guard (D9944) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on March 11, 2022. 
 
You asked the Plan to pay for a guard. You say that you did not know the guard was so pricey. The Plan denied 
your request. The Plan says an occlusal guard (D9944) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular (lower) denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your bottom dentures and have a 
hard time chewing without them. You also say the absence of a lower denture affects your speech. 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 July 28, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete mandibular (lower) denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046-26 billed for date of service February 
16, 2021. 
 
You asked the Plan to pay for procedure code 71046-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 16, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 71046-23 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71046-26 billed for date of service 
February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that it was a different type of exam that you had 
done earlier in the year. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 26, 2021, and 
May 4, 2021. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) 
provided on November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on January 8, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you do not believe you were 
enrolled in the Plan. The Plan denied your request. The Plan says non-transport ambulance services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services you received on 
January 8, 2022.