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

 
We decided that the Plan does not have to pay for core build up on tooth #14 (D2950) and retainer crowns on 
tooth #12 and 14 (D2740) provided on October 5, 2021. 
 
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 your benefit for core build up has already been exhausted. The 
Plan also says that retainer crowns 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, certain limitations apply. The record 
shows your benefit for core build up was exhausted on date of service October 5, 2021. Retainer crowns 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 #14 (D2950) and retainer crowns on tooth #12 and 14 (D2740) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on June 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you changed dentists and needed this service. 
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 November 5, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on June 17, 
2022. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you were unaware you would 
be charged a hospital copay because you assumed it was a free-standing facility and not a hospital. 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 $200 
copayment for outpatient hospital services.  
 
 
  You have been asked to pay a $200 copayment for an arthrocentesis performed at an outpatient hospital 
facility. This item/service falls within the outpatient hospital 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 an arthrocentesis provided on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular interim partial denture (D5821), or pay more 
for the problem focused limited oral evaluation (D0140), and first intraoral periapical x-ray (D0220) provided 
on June 22, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the mandibular interim partial denture, and to pay more for the problem focused 
limited oral evaluation, and first intraoral periapical x-ray. You say that your tooth broke at the gum line, and 
the provider was not able to remove the root, but referred you to a periodontist. You also say that these services 
were medically necessary. The Plan denied your request. The Plan says the mandibular interim partial denture 
is not a covered benefit. The Plan also says that the OON member liability was applied correctly per your plan 
benefits for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
 
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 mandibular interim partial denture 
(D5821) is not among those covered under this benefit. You are also responsible for the difference between the 
billed amount and allowed amount for the covered dental services because they were rendered by an OON 
provider. Therefore, we decided that the Plan does not have to pay for the mandibular interim partial denture 
(D5821), or pay more for the problem focused limited oral evaluation (D0140), and first intraoral periapical x-
ray (D0220) provided on June 22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 2, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 the office visit provided on March 2, 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 dental services provided by an opt-out provider on April 5, 
2021. 
 
You asked the Plan to pay for dental services. You say that you would like reimbursement for these services. 
The Plan denied your request. The Plan says this provider has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral evaluation 
(D0120), and the panoramic radiographic image (D0330) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 cleaning (D1110), periodic oral evaluation (D0120), and the panoramic radiographic image (D0330) 
provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this fee is in addition to the primary 
anesthesia procedure and is separately payable based on ASA guidelines. The Plan denied your request. The 
Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2)

You asked the Plan to pre-approve the porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2). You say that you are having tooth pain and were advised by your dentist to do the bridge. You say you cannot afford the cost and needs insurance to cover the services. The Plan denied your request. The Plan says the services do not meet criteria for coverage.

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 Plan covers the porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2) when the services are medically necessary and reasonable. 

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 porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2). Our reviewer says that the services are not medically necessary. Our physician reviewer found the supporting bone on teeth #23 and #25 is less than 50%, meaning there is not enough bone support that would be considered stable for a bridge prosthetic. The requested bridge would not be medically necessary.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2) have not been met. Therefore, we decided that the Plan does not have to pre-approve the porcelain fused pontic (D6240) and the porcelain fused crown (D6750 x2)
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says treatment sessions have become repetitive. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that endurance training is repetitive exercise, even as maintenance and 
not skilled therapy. A weekly therapy visit to maintain endurance goals is not a physiologically or evidence 
based skilled therapy program 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prescription of optical and physical characteristics of and fitting of contact lens (92310) provided on February 19, 2021.

You asked the Plan to pay for the contact lens fitting. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the prescription of optical and physical characteristics of and fitting of contact lens (92310) provided on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 10, 2022, to 
March 14, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says payment of DRG 193 remains not supported because secondary diagnosis code J96.21 
did not qualify for reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21, defined as acute 
and chronic respiratory failure with hypoxia. 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 pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support secondary diagnosis code J96.21. Our physician reviewer found that there was no documentation of the 
use of 5 liters or greater oxygen, bilevel positive airway pressure or mechanical ventilation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from March 10, 2022, to March 14, 2022, at the DRG originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional unit of an epidural steroid injection 
(64484). 
 
You asked the Plan to pre-approve an additional unit of an epidural steroid injection. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TFESIs involving a maximum of two (2) levels in 
one spinal region are considered medically reasonable and necessary. 
 
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 an additional unit of an epidural steroid 
injection. Our reviewer says that the requested service is not medically reasonable and necessary. Our 
physician reviewer found that the request exceeds the utilization criteria. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional unit of an epidural steroid injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an additional unit of an epidural steroid injection 
(64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tire equipment. 
 
You asked the Plan to pre-approve pneumatic propulsion tire equipment. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the equipment is requested specifically for 
outdoor use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this equipment may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve pneumatic propulsion tire equipment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture (D5110) and the partial denture 
(D5214) for tooth #18 provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 or services was exhausted on the date of service of May 4, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete denture (D5110) and the partial 
denture (D5214) for tooth #18 provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant supported crown (D6065) for tooth #29, 
#30, and #31. 
 
You asked the Plan to pre-approve the dental service. You say that you had prior authorization for the 
supported implants, and it expired. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because dental implants and all associated services 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 the 
implant supported crown (D6065) for tooth #29, #30, and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you thought the service would have been 
covered at 20% for OON services. 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 November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on October 14, 
2021. 
 
You asked the Plan to pay for the dental services. You say that the requested service should be covered. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested full mouth debridement (D4355) but is limited to one procedure every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested full mouth debridement (D4355) was exhausted on date of service 
September 30, 2021. Therefore, we decided that the Plan does not have to pay for full mouth debridement 
(D4355) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 1, 2022. 
 
You asked the Plan to pay for an evaluation. You say that your provider did not tell you that the third 
evaluation would not be covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 February 18, 2022, and 
March 19, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1208) provided 
by a participating provider on May 18, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that the dentist never told you 
this was no longer covered. The Plan denied your request. The Plan says the denied 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 
topical application of fluoride varnish (D1208) provided by a participating provider on May 18, 2022.