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

 
We decided that the Plan does not have to pay for a limit oral evaluation (D0140) provided by an out-of-
network provider on July 30, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this 
because it was an emergency. The Plan denied your request. The Plan says the benefit limit 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 covers two limited 
oral evaluations per year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have 
to pay for a limit oral evaluation (D0140) provided by an out-of-network provider on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the provider does not check 
your eligibility prior to doing the work, and now your claim is being denied. The Plan denied your request. The 
Plan says this service exceeds the maximum allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 25, 2019 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
The services at issue were billed under code 80050. Medicare does not cover or pay for services billed under 
this code. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81238, 81225, 81230, 81241, 81291, 81240, 
81226, 81306, 81328, 81335, 81231, 81283) provided August 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81238, 81225, 81230, 81241, 81291, 81240, 81226, 81306, 
81328, 81335, 81231, 81283) provided August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a crown (D2740), and a core build-up. You say that the enrollee has a 
history of fracturing teeth in the past. The Plan denied your request. The Plan says the requested dental services 
are not covered 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 pre-approve a 
crown (D2740), and a core build-up (D2950) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920), prefabricated post 
and core in addition to crown (D2954), periodic oral evaluation (D0120), first intraoral periapical x-ray 
(D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), custom 
fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058) provided from March 
3, 2021, to October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that the treating providers have changed their opt out 
status. You also say that it is your understanding that this would update with Centers for Medicare & Medicaid 
Services (CMS) and claims would no longer deny for the opt out reason. The Plan denied your request. The 
Plan says the maximum benefit allowed by the enrollee's dental plan has been paid for the 2021 benefit year. 
 
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 Plan offers up to $500 every year 
for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services 
combined. The contract says that the enrollee is responsible for any amount above the coverage limit. The 
record shows that the enrollee met the annual maximum benefit on February 22, 2021 and the enrollee's annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond crown (D2920), prefabricated post and core in addition to crown (D2954), periodic oral 
evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), 
bitewing x-rays (D0274), prophylaxis (D1110), custom fabricated abutment (D6057), and abutment supported 
porcelain/ceramic crown (D6058) provided from March 3, 2021, to October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture adjustment (D5411) provided on December 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service was covered under your plan at the 
time you received your denture. The Plan denied your request. The Plan says denture adjustment is not listed as 
a covered service. 
 
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 denture adjustment is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture 
adjustment (D5411) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the retainer crowns (D6740 x 2) and 
pontic (D6245) provided on December 17, 2021. 
 
You asked the Plan to pay an additional amount for the fixed bridge. You say that you would not have had 
these services if you had known they would not be covered. You say that you cannot afford this bill. You also 
say that your dental allowance of $1,000 should be applied. The Plan denied your request. The Plan says the 
claim denied correctly. 
 
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 annual maximum benefit of $1,000 
has been exhausted. The record shows that the Plan reprocessed this claim and applied a $1,000 payment. 
Therefore, we decided that the Plan does not have to pay an additional amount for the retainer crowns (D6740 
x 2) and pontic (D6245) provided on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for anesthesiology services provided on March 9, 2021. 
 
You asked the Plan to waive the coinsurance for anesthesiology services. You say that you were transferred to 
a different hospital due to the technical nature of the procedure you needed. You also say in a life-or-death 
situation you are not thinking about if services are in or out-of-network when you are being sent somewhere 
else to save your life. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing your condition was not, or 
was no longer, an emergency. Therefore, the Plan cannot cover the service at the out-of-network rate.  
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 for in-network provider and professional services at an 
inpatient hospital. The contract also says if you get authorized inpatient care at an out-of-network after your 
emergency condition is stabilized, your cost is the cost-sharing you would pay at a network hospital. 
 
The Plan says you must pay $192.31, which is 30% coinsurance for out-of-network anesthesiology services. 
Based on the Plan contract, however, you cannot be asked to pay more than $0 for in-network anesthesiology 
services. Therefore, we decided that the Plan has to waive the coinsurance for anesthesiology services provided 
on March 9, 2021. 
  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on January 28, 2021, and  
January 29, 2021. 
 
You asked the Plan to pay for observation care. The Plan denied your request. The Plan says the service is a 
covered benefit, but the member had coverage with another insurance as her primary insurance plan beginning 
June 1, 2011. The Plan cannot process the claim until the claim has been submitted and processed by the 
members primary Plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has cannot 
process the claim until the claim has been submitted and processed by the primary Plan. As the secondary 
insurer, the Plan cannot be held responsible for observation care until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for observation care provided on 
January 28, 2021, and January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a video electroencephalogram (EEG) (codes 95700, 
95718, and 95713). 
 
You asked the Plan to pre-approve a video electroencephalogram. You say that you are having seizures and 
want to get to the bottom of why it is happening. The Plan denied your request. The Plan says criteria for this 
service are not met because you have not had a resting EEG performed. 
 
The Plan follows Medicare rules. Medicare rules say that ambulatory electroencephalogram (EEG) monitoring 
is a diagnostic procedure for patients in whom a seizure diathesis is suspected but not defined by history, 
physical or resting EEG. Ambulatory EEG can be utilized in the differential diagnosis of syncope and transient 
ischemic attacks if not elucidated by conventional studies. Ambulatory EEG should always be preceded by a 
resting EEG. 
 
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 a video electroencephalogram. Our 
reviewer says that the requested video electroencephalogram is not medically necessary. Our physician 
reviewer found Medicare criteria state that ambulatory EEG should always be preceded by a resting EEG. Your 
medical records do not contain documentation of a resting EEG. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a video electroencephalogram have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a video electroencephalogram (EEG) (codes 95700, 95718, and 95713).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on December 1, 2021 to 
December 2, 2021. 
You asked the Plan to pay for these services. You say that you do not know what you are paying for. The Plan 
denied your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
rendered on December 1, 2021 to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from March 3, 2021, to April 
12, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told these services would be covered. 
The Plan denied your request. The Plan says they have agreed to reprocess your claims and have provided 
reimbursement to you in the amount of $3,000. However, your annual benefit maximum for supplemental 
dental care in 2021 was $3,000, and you are responsible for the remaining costs. 
 
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 a maximum 
of $3,000 every year for non-Medicare covered preventative and comprehensive dental services combined. You 
are responsible for any amount above the dental coverage limit. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided in excess of the $3,000 annual benefit maximum are not covered under this benefit. The Plan has indicated that they will provide payment for the full $3,000 amount for these services; however, the remaining cost is your responsibility. Therefore, we decided that the Plan does not have to pay for the dental services provided from 
March 3, 2021, to April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam you had on December 7, 2021. 
 
You asked the Plan to pay for the oral exam. You say that you do not know why the exam wasn't paid for. The 
Plan denied your request. The Plan says the benefit limit has been exceeded. 
 
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 services are subject to a 
benefit limitation. The Plan covers two oral exams per year. The records show that you received covered oral 
exams on May 12, 2021, and November 22, 2021. This means that the requested exam is your third exam of 
2021, which exceeds the benefit limit. Therefore, we decided that the Plan does not have to pay for the oral 
exam you had on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical debridement provided on October 
27, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this charge is excessive and 
should be reduced. The Plan denied your request. The Plan says the copayment amount you are being charged 
is correct. 
 
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 $350 
copayment for outpatient surgery at an outpatient hospital facility.    
You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 surgical debridement 
provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral exam (D0140) unspecified preventive procedure, 
by report (D1999) provided December 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that this was not a normal visit or 6-month checkup. 
This should be covered as a non-routine service. The Plan denied your request. The Plan says this service 
exceeds the maximum benefit allowed or is not covered under the Plan 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 Plan covers oral exams 2 
times a year. The records show that the Plan had already covered for two oral exams and paid on January 25, 
2021 and April 22, 2021. Therefore, the benefit has been exhausted. The health Plan contract also says that 
services not listed is not covered by the Plan. D1999 is listed as a covered service, therefore, is not covered. 
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 limited 
oral exam (D0140) unspecified preventive procedure, by report (D1999) provided December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the treatment sought was medically 
necessary as per the enrollee's condition, hereby attached complete medical records to support the service. The 
Plan denied your request. The Plan says the records do not support the service billed.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the Plan had verified that the genetic testing 
was not ordered/approved by ordering provider. The provider did not bill as required by Medicare coding 
regulations. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology 
procedure (81479) provided October 6, 2021.