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

 
We decided that the Plan does not have to pre-approve an implant (D6010) for tooth #4. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
implants 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 pre-approve an 
implant (D6010) for tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3020 x 2) provided on August 24, 2022. 
 
You asked the Plan to pay for these 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 a covered benefit for the 
enrollees condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
  
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.  
Although orthotics may be appropriate for him, neither Medicare nor the Plan provides coverage of orthotics 
for his condition. Additionally, Medicare rules say that with the exception of the situations described, 
orthopedic footwear billed using code L3020 will be denied as non-covered. Therefore, we decided that the 
Plan does not have to pay for the foot orthotics (L3020 x 2) provided on August 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from May 22, 2022, to May 30, 
2022. 
 
You asked the Plan to pay for the inpatient care. You say that these services should be covered. The Plan 
denied your request. The Plan says this 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. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 22, 2022. The services in question were provided before the end of that month. Additionally, the record shows that the enrollee re-enrolled in the hospice benefit on 
May 30, 2022. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from 
May 22, 2022, to May 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140), limited oral evaluation - problem focused (D0140), and intraoral - periapical first 
radiographic image (D0220) provided on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration. You also 
say that the services should be covered as upon doing a provider search this dentist was listed as an in-network 
provider. 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 an extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), limited oral 
evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) provided on 
August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2), two abutment 
supported porcelain fused to metal crowns (D6060 x2), and two implant supported crowns (D6066 x2). 
 
You asked the Plan to pre-approve the endosteal implants, abutment supported porcelain fused to metal crowns, 
and implant supported crowns. You say that you are not satisfied with the Plan's denial. The Plan denied your 
request. The Plan says these services are not covered under your benefit 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 pre-approve two 
endosteal implants (D6010 x2), two abutment supported porcelain fused to metal crowns (D6060 x2), and two 
implant supported crowns (D6066 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service May 4, 2022. 
 You asked the Plan to pay for procedure code 12001. The Plan denied your request. The Plan says payment for 
code 12001 is bundled into payment for code 29125. 
 
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 12001 is a column II code to column I code 29125. 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 12001 
billed for date of service May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(95220) provided on September 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision service. You say that this should have been paid. The Plan denied your 
request. The Plan says the service you received is not covered when performed by an out-of-network provider. 
 
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 provider in this case is not a network provider with the Plan. 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 the fundus photography with interpretation and report (95220) 
provided on September 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and refraction (92015) provided on 
January 14, 2022. 
 
You asked the Plan to pay for the eye exam and refraction. You say that you are being charged $25 for a 
routine eye care appointment because the doctor made a note in your file. You also say that you should not be 
responsible for a copayment because no additional care or follow up was done. The Plan denied your request. 
The Plan says the copayment amount you are being charged is correct. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a $25 copay 
for each specialist visit for eye exams involving diagnosis and treatment for diseases and conditions of the eye. 
The record shows that you were treated for at least one medical diagnosis, and this was not a routine exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam and refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92004) and refraction 
(92015) provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient clinic visit provided on May 12, 
2022 
 
You asked the Plan to waive the deductible for outpatient clinic visit. You say that you disagree with the cost 
share. 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 $375 
deductible for Section 1.2 What is your plan deductible? 
 
You have been asked to pay a $375 deductible for outpatient clinic visit. The total amount you are being asked 
to pay is $130.64 towards your deductible. 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 deductible for outpatient 
clinic visit provided on May 12, 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 August 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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 August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory services provided on April 
08, 2022. 
 
You asked the Plan to waive the coinsurance for the laboratory services. You say that the services should be a 
covered benefit. 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 20% 
coinsurance for lab services. 
 
You have been asked to pay 20% coinsurance for the laboratory services. This item/service falls within the lab 
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. Please note that while the exam itself was covered, the urinalysis performed is not, and therefore the 
coinsurance applies. 
 
 
  
 
 Therefore, we decided that the Plan does not have to waive the coinsurance for the laboratory services 
provided on April 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367), surgical extraction (D7210), and removal of torus palatinus (D7472) provided from 
July 21, 2022, to August 4, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, surgical extraction, and removal of 
torus palatinus. You say that the provided services were in connection with an extraction of a tooth as well as 
follow up care due to the extraction. You also say that according to page 4-89 of the plan materials, under 
extractions and oral surgery procedures, it appears that the subject services should have been covered. The Plan 
denied your request. The Plan says these services are not covered benefits under the enrollee's dental plan. The 
Plan also says the enrollee was not enrolled in the supplemental Dental Rider on this date of service, which 
does allow for coverage of the surgical extraction (D7210). 
 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 cone 
beam computed tomography (CT) capture and interpretation (D0367), surgical extraction (D7210), and 
removal of torus palatinus (D7472) provided from July 21, 2022, to August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spherocylinder trifocal lenses (codes V2303 and V2304) 
and anti-reflective coating (V2750) provided on June 28, 2022. 
 
You asked the Plan to pay for the spherocylinder trifocal lenses and anti-reflective coating. You say that prior 
to getting these glasses, you called the number on the back of your card, and were told that since your last pair 
of glasses was purchased in December 2020, you could get a new pair anytime during the 2022 calendar year. 
The Plan denied your request. The Plan says this claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 for eyewear every year. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that the eyewear you received cost a total of 
$559.00. The Plan applied the full $300 allowance toward this amount, leaving you with a remaining balance 
of $259.00, and exhausting your eyewear allowance for the 2022 plan year. Based on this information, we 
decided that the Plan's rules for coverage of the spherocylinder trifocal lenses and anti-reflective coating have 
not been met. Therefore, we decided that the Plan does not have to pay for the spherocylinder trifocal lenses 
(codes V2303 and V2304) and anti-reflective coating (V2750) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel this service should be covered. You 
also say that you had discomfort and it had to be examined, which makes this the third exam this 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 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 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services provided did not need a prior 
authorization. The Plan denied your request. The Plan says services can be obtained from an in-network 
provider. 
 
 
 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 wound care services provided on July 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer. You say that the services are 
medically necessary. The Plan denied your request. The Plan says these services are considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion interspinous 
spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature 
do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition as discussed above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex Superion interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you doctor says the compression 
stockings are medically necessary. The Plan denied your request. The Plan says the compression stockings are 
not a Medicare covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient dialysis provided on May 3, 
2022, to May 7, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient dialysis. You say that you disagree with the 
coinsurance. 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 20% 
coinsurance for services to treat kidney disease.  
 
You have been asked to pay a 20% coinsurance for outpatient dialysis. The total allowed amount for outpatient 
dialysis is $1,200. You are being asked to pay $240 ($1,200 x 20% = $240). This item/service falls within the 
services to treat kidney disease 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 
outpatient dialysis provided on May 3, 2022, to May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on June 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial for date of service 
June 6, 2022 for services provided by a participating provider. The Plan denied your request. The Plan says 
your benefit for the requested item or service $2,000 dollar limit was met. 
 
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 June 20, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on June 6, 
2022.