Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses flex-walk system and 
addition to lower limb prosthesis vertical shock reducing pylon feature. 
 
You asked the Plan to pre-approve all lower extremity prostheses flex-walk system and addition to lower limb 
prosthesis vertical shock reducing pylon feature. You say that you are in desperate need of this socket and foot. 
The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that replacement prostheses are only covered for certain 
indications. 
 
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 all lower extremity prostheses flex-
walk system and addition to lower limb prosthesis vertical shock reducing pylon feature. Our reviewer says that 
the documentation does not support that the requested items are medically reasonable or necessary. Our 
physician reviewer found you have a right below the knee amputation and your current prosthetic foot is 
reported to be broken. Based on the medical records provided there is no documentation that the prosthetic foot 
at issue in this case meets Medicare criteria for medically reasonable and necessary. The provided records do 
not document that your current (broken) prosthetic foot is no longer under warranty and requires replacement 
covered by Medicare. This means that your current item is still under warranty and the requested item exceeds 
your needs. Therefore, you do not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of all lower extremity prostheses flex-walk system and addition to lower limb 
prosthesis vertical shock reducing pylon feature have not been met. Therefore, we decided that the Plan does 
not have to pre-approve all lower extremity prostheses flex-walk system and addition to lower limb prosthesis 
vertical shock reducing pylon feature.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 8, 2021, billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were billed appropriately 
and are supported in the medical record. The Plan denied your request. The Plan says these services should be 
billed with a single panel code rather than the individual gene codes. 
 
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 
August 8, 2021, billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided February 11, 2022. 
 
You asked the Plan to pay for the tooth extraction. You say that this service was necessary due to dental pain. 
The Plan denied your request. The Plan says this service is 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 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 the 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy (29876) provided on December 28, 2021. 
 
You asked the Plan to pay for the knee arthroscopy (29876). You say that the claim should be reviewed and 
processed for payment. The Plan denied your request. The Plan says procedure code 29881 has been 
overturned. The Plan also says an assistant surgeon may not be paid for procedure code 29876. 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29876. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
knee arthroscopy (29876) have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee arthroscopy (29876) provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on April 19, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you were unaware this service was not covered. The 
Plan denied your request. The Plan says local anesthesia (D9215) 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 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 local 
anesthesia (D9215) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) provided on January 19, 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 payable as the 
documentation does not show proof that deep cleaning has been done previously. 
 
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. Specifically, the Plan contract states that periodontics are covered every six to  
thirty six months. However, the contract does not specify covered periodontal services, nor does it indicate 
frequencies or limitations. Additionally, the rationale indicated by the Plan for this denial, is not supported in 
the contract. Therefore, the Plan has not substantiated their denial and we must find in your favor. Therefore, 
we decided that the Plan has to pay for the periodontal maintenance (D4910) provided on January 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
November 30, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was reported appropriately. The Plan 
denied your request. The Plan says this service is not supported as billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records do not 
note the time spent providing these services. Without this information, a time-based code such as 99291 cannot 
be verified. Based on this information, we decided that Medicare rules for coverage of critical care have not 
been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for 
date of service November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service July 12, 2021. The Plan contract 
covers complete dentures once every five years. You previously received these items on July 12, 2021. 
Therefore, you have exhausted the allowable benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for maxillary complete dentures (D5110) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told you could only get dentures 
every five years. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for maxillary complete dentures (D5110) provided 
on March 23, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel the service 
should be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $150 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 waive the copayment for 
ambulance transportation provided on February 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on February 18, 2022. 
You asked the Plan to pay for lab services. You say that these services were necessary in determining the 
appropriate medical treatment for the enrollee. 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 laboratory (lab) services provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinalysis test provided on October 11, 2021, by an OON 
provider. 
 
You asked the Plan to pay for a urinalysis test. You say that you are requesting reconsideration to review the 
pre-certification for retro authorization with supporting documents. The Plan denied your request. The Plan 
says the out-of-network services were not authorized. 
 
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 a urinalysis test provided on October 11, 2021, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210) provided on March 4, 2022. 
 
You asked the Plan to pay for the surgical extractions. You say that you are on a limited income and need help 
paying for these services. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 
benefits and provider eligibility. 
 
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 
surgical extractions (D7210) provided on March 4, 2022.  
 
Your complaint about being disappointed in the lack of the Plans coverage 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided from February 
22, 2022, to March 4, 2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the supplies were always 
covered in the past. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 each prosthetic or orthotic item, including ostomy supplies. 
 
 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Ostomy Pouch (A5063)  February 22, 2022 $49.40 $9.88 
Adhesive Remover (A4456)  February 22, 2022 $11.00 $2.20 
Skin Barrier Wipes (A5120)  February 22, 2022 $5.50 $1.10 
Ostomy Paste (A4405)  February 22, 2022 $13.60 $2.72 
Skin Barrier (A4414)  March 4, 2022 $96.80 $19.36 
Total:  $35.26 
 
You have been asked to pay a total of $35.26, which is 20% of the allowed amount for the ostomy supplies. 
The ostomy supplies fall within the Prosthetic Devices and Related Supplies 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 ostomy supplies provided from February 22, 2022, to March 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis and periodic dental services (D0120, D1110) 
provided by an out-of-network provider on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plan's 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 prophylaxis and periodic dental services (D0120, D1110) provided by an out-of-network provider on 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a resin-based composite filling on tooth # 
11 (D2332) and a resin-based composite filling on tooth #12 (D2394) and does not have to pay for periapical x-
rays (D0220, D0230) provided on March 11, 2022. 
 
You asked the Plan to waive the copayments for fillings. You say that these services were done by a dental 
assistant. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
The Plan also says that your benefit for periapical x-rays 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 you must pay a $25 
copayment for each in-network filling.  
 
You have been asked to pay a $25 copayment for each filling. Fillings fall 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, certain limitations apply. The record 
shows your benefit for periapical x-rays was exhausted on date of service March 11, 2022. Therefore, we 
decided that the Plan does not have to waive the copayments for a resin-based composite filling on tooth # 11 
(D2332) and a resin-based composite filling on tooth #12 (D2394) and does not have to pay for periapical x-
rays (D0220, D0230) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
dental cleaning (D1110), and bitewing x-rays (D0272) provided March 14, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the provider was 
OON. 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 Plan's 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 periodic oral evaluation - established patient (D0120), dental cleaning (D1110), and bitewing x-
rays (D0272) provided March 14, 2022, by an out-of-network (OON) provider.