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

 
We decided that the Plan does not have to pay for the orthotics services rendered on October 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97760 is not supported. 
 
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 97760 is orthotic(s) management and training (including 
assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, 
initial orthotic(s) encounter, each 15 minutes. 
 
We find that CPT code 97760 is not supported in the medical record. Specifically, the records do not support 
the services were provided on the billed date of service. 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 
pay for the orthotics services rendered on October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingivectomy/gingivoplasty provided by an out-of-network 
provider on May 9, 2022. 
 
You asked the Plan to pay for a gingivectomy/gingivoplasty. You say that you would like the Plan to pay for 
these services. The Plan denied your request. The Plan says the rendered dental 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 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 
gingivectomy/gingivoplasty provided by an out-of-network provider on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival flap procedure, including root planing - four or 
more contiguous teeth or tooth bounded spaces per quadrant (D4240), bone replacement graft  retained natural 
tooth  first site in quadrant (D4263), and bone replacement graft  retained natural tooth  each additional site 
in quadrant (D4264) provided on April 25, 2022. 
 
You asked the Plan to pay for the gingival flap procedure and bone replacement grafts. You say that you would 
like these services covered. 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 pay for the 
gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per 
quadrant (D4240), bone replacement graft  retained natural tooth  first site in quadrant (D4263), and bone 
replacement graft  retained natural tooth  each additional site in quadrant (D4264) provided on April 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 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 dental 
services on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided by a participating provider on June 20, 2022. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation. 
You say that this was coded incorrectly. The Plan denied your request. The Plan says the rendered dental work 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided by a participating 
provider on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 1, 2022.

You asked the Plan to pay for procedure code 70450. You say that the services at issue were billed correctly. 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 July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic on tooth #23, 24, 25, and 26 (D6245) provided on 
June 20, 2022. 
 
You asked the Plan to pay for pontics. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says pontics (D6245) 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
on tooth #23, 24, 25, and 26 (D6245) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper and lower partial dentures (D5213, D5214) 
provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
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 your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the upper and lower partial dentures (D5213, D5214) provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received an x-ray, but nothing was done 
about your teeth. 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 October 29, 2019. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 23, 
2022.  
 
Your complaint about the benefit design 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.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 13, 2022.

You asked the Plan to pay for the hospital care. You say that this should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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. Although the enrollee revoked their hospice election on the date of service in this case. Original Medicare is responsible for coverage Part B benefits until the last day of the month in which hospice is revoked. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77387 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 77387. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 77387 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77387 is not valid for Medicare purposes. Additionally, code 77387 has a Professional 
Component (PC)/Technical Component (TC) indicator of 0. Modifiers 26 and TC cannot be used with this 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 77387 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 77387 billed for 
date of service February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
June 21, 2022. 
 
You asked the Plan to pay for a crown. You say that you were unaware that this would not be covered. The 
Plan denied your request. The Plan says the rendered dental 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 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 crown 
(D2740) provided by a participating provider on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210), a 
panoramic radiographic image (D0330), and prophylaxis (D1110), provided by an out-of-network provider on 
October 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe that these services should be 
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 a complete series of radiographic images (D0210), a panoramic radiographic image (D0330), and 
prophylaxis (D1110), provided by an out-of-network provider on October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the urgent care visit (99203) provided on June 11, 2022.

You asked the Plan to waive the cost share amount for the urgent care visit. You say that you went to urgent care for a chest x-ray. You say that the initial x-ray was not clear. You also say that you would like the second x-ray to be covered. 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 a $45 copayment for Urgently Needed Services. 

You have been asked to pay a $45 copayment for the urgent care visit. This service falls within the Urgently Needed 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. Additionally, the record shows that the copayment is for the urgent care visit and there was no charge for the x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to waive the cost share amount for the urgent care visit (99203) provided on June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99379 billed for date of service March 29, 2022.

You asked the Plan to pay for procedure code 99379. You say that the services at issue were billed correctly. The Plan denied your request. The Plan says procedure code 99379 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 99379 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99379 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99379 billed for date of service March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 10, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you get two free cleanings a year. 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 a total of $94, which is the difference between the out-of-network providers 
charges and the Plans payment for an evaluation and cleaning. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355) provided on July 7, 2022. 
 
You asked the Plan to pay for a full mouth debridement (D4355). You say that because of the pandemic, you 
could not get to a dentist. You also say that they needed to do this because there was so much plaque built up 
from you not seeing a dentist for two years. The Plan denied your request. The Plan says dental procedure 
codes not listed on the dental benefit grid are excluded from coverage. The Plan also says that the procedure in 
dispute, a full mouth debridement (D4355), is not listed on the dental benefit grid as a covered service and is 
therefore excluded from coverage. 
 
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 full 
mouth debridement (D4355) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) for tooth #10 provided on 
May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 a resin-based composite was exhausted on date of service May 31, 2022 with tooth #7. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2331) for tooth #10 
provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D photographic images (D0350) provided on August 1, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the Plan's website told you that the dentist was 
in-network, and you would like for the dental service to be covered. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because 2D photographic images 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, 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 2D 
photographic images (D0350) provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve partial dentures. You say that the enrollees dental health is at risk. The Plan 
denied your request. The Plan says that the benefit for the service at issue has been exhausted. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan provided inconsistent information regarding exhaustion of the benefit 
and sent us an incomplete 2022 EOC. Therefore, we decided that the Plan has to pre-approve an upper partial 
denture (D5213).  
 
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.