Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 8, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services provided on June 8, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator provided on May 25, 
2021, by an OON provider. 
 
You asked the Plan to pay for an automatic external defibrillator. You say that you would like the claim to be 
reconsidered and paid. 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 an automatic external defibrillator provided on 
May 25, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220), a core build-up (D2950), and a 
crown (D2740), provided by an out-of-network provider on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 intraoral imaging (D0220), a core build-up (D2950), and a crown (D2740), provided by an out-of-
network provider on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the transfer to LTACH is medically 
necessary, and his treatment and care are in accordance with generally accepted standards of medical practice. 
The Plan denied your request. The Plan says LTACH is not medically necessary, and the enrollee's needs can 
be met at a lower level of care, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, 
outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with intestinal obstruction in the setting of enterocutaneous 
fistula and required operative intervention. The record indicates that the enrollee has ongoing acute medical 
issues and still requires acute care services before transitioning to a lower level of care.    
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on June 8, 2022. 
 
You asked the Plan to pay for x-rays. You say that these x-rays were medically necessary. The Plan denied 
your request. The Plan says periapical x-rays (D0220, D0230) are 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 periapical 
x-rays (D0220, D0230) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the administration of nitrous oxide (D9230) and a 
porcelain crown (D2751) provided on December 8, 2021, and January 28, 2022. 
 
You asked the Plan to reimburse you for the dental services. You say the treatment and payments took place in 
2022, not in 2021. The Plan denied your request. The Plan says you received dental services on December 8, 
2021, at which point, you had already received the maximum amount of coverage allowed. The dental claims 
show no payments were billed or paid for dental services provided to you on January 28, 2022. The Plan says 
you cannot request payment using your 2022 dental reimbursement allowance for services provided in 2021.    
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. Though the Plan offers a dental benefit in excess of Medicare coverage, coverage is limited 
to an annual reimbursement allowance of $1,000. Regarding the dental services on December 8, 2021, on that 
date of service your $1,000 maximum benefit for 2021 had been exhausted.  
 
 To date, the Plan has not received a claim for services provided on January 28, 2022, nor is there a payment 
history for this date of service. Therefore, we decided that the Plan does not have to reimburse you for the 
administration of nitrous oxide (D9230) and a porcelain crown (D2751) provided on December 8, 2021, and 
January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #29 (D2950) provided on March 2, 
2022. 
 
You asked the Plan to pay for core build up. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says core build up (D2950) is not covered by your supplemental 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 core build 
up on tooth #29 (D2950) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a partial maxillary denture (D5213) provided on 
February 14, 2022. 
 
You asked the Plan to pay more for a partial denture. You say that if you had known that you were going to 
have to pay this large sum you would not have had the work done. The Plan denied your request. The Plan says 
your annual maximum amount has been 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. 
 
The record shows your annual maximum amount has been met. 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 
when your annual maximum amount has been met. Therefore, we decided that the Plan does not have to pay 
more for a partial maxillary denture (D5213) provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a CT scan and physical therapy provided 
from June 10, 2022, to June 13, 2022. 
 
You asked the Plan to waive the copayments for a CT scan and physical therapy. You say that you should not 
be responsible to pay this. 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 $110 
copayment for a CT scan and a $40 copayment for physical therapy.  
 
You have been asked to pay $109.24 for a CT scan and a $40 copayment for each physical therapy service. 
Your contract with the Plan says you must pay a $110 copayment for a CT scan; however, you are only being 
asked to pay $109.24 which is less than the standard copayment amount. A CT scan falls within the basic radiological services benefit category. Physical therapy falls within the physical therapy 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 copayments for a CT scan and physical therapy provided from June 10, 
2022, to June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99213) and x-ray (73630) 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for the physician services. You say that you were seeing this provider for 
the care of your open wound. You say that you should be able to continue this care despite the provider no 
longer being in network as of October 2021. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 reimburse you 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 reimburse you for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for the office visit (99213) and x-ray 
(73630) provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that your teeth have started breaking off in the 
gums and now you need the partial denture. You say you are unable to chew food due to your missing and 
cracked 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 March 28, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were not received from your assigned dentist. 
 
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 
covered under this benefit when not received from your assigned dentist. Therefore, we decided that the Plan 
does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) 
provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on July 18, 2022. 
 
You asked the Plan to pay for a guard. You say that this service was medically necessary. 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 July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microsurgical techniques, requiring use of operating 
microscope (List separately in addition to code for primary procedure) 69990.  
You asked the Plan to pre-approve the surgical procedure. You say that this multilevel lumbar fusion operation 
is an inpatient surgery requiring 2-3 nights in the hospital to monitor drain output, provide appropriate 
postoperative pain control and assist with the initial surgical recovery The Plan denied your request. The Plan 
says CPT code 69990 is to be used with only with specific other CPT codes, as specified in Medicare 
guidelines. 
 
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 the 
surgical procedure is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the microsurgical techniques, requiring use of operating microscope (List 
separately in addition to code for primary procedure) 69990.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral imaging 
(D0230), bitewings (D0274), and prophylaxis (D1110), provided by an out-of-network provider on January 24, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this provider was out-of-
network at the time of your visit. 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 periodic oral evaluation (D0120), intraoral imaging (D0230), bitewings (D0274), and prophylaxis 
(D1110), provided by an out-of-network provider on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for surgical services. You say that you were advised you had to get your fistula 
unclogged. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advanced. 
 
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 surgical services provided on May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on January 19, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a drug test. You say that on the appeal request, the claim was denied as charges 
are covered under a capitation agreement/managed care plan. 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 drug test provided on January 19, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam provided on May 12, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that the member's previous dentist retired 
and she had to go to a new one.  You believe that this service was supposed to be covered by the Plan. 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. The Plan only covers 
comprehensive oral exams once every 36 months. The record shows the benefit for the requested item or 
service was exhausted on date of service November 14, 2019. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral exam provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy billed with code 97026-GP for date of 
service March 23, 2022. 
 
You asked the Plan to pay for the infrared therapy services. You say that these services were medically 
necessary for the patient. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered because it is not 
considered reasonable and necessary. Therefore, we decided that the Plan does not have to pay for infrared 
therapy billed with code 97026-GP for date of service March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit} provided on April 29, 2022, to April 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit} provided on April 29, 2022, to 
April 30, 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 comprehensive oral exam (code D0150) you had on June 
8, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that your dentist dropped your insurance 
plan, so you had to go to another dentist. The Plan denied your request. The Plan says your benefit for the 
requested 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 May 26, 2022. There is 
no exception allowing for coverage of an additional exam if your dentist leaves the network. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you had on June 8, 
2022.