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

 
We decided that the Plan does not have to pay for the dental services on September 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 April 8, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the bone replacement graft for ridge 
preservation-per site (D7953) provided on August 29, 2022. 
 
You asked the Plan to issue reimbursement 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 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the bone replacement graft for ridge preservation-per site (D7953) provided on August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of Methadone (G2078) provided on 
September 5, 2022. 
 
You asked the Plan to pay for the take-home supply of Methadone. You say that you believe the Plan did not 
have all the necessary information to process this claim correctly. The Plan denied your request. The Plan says 
this provider was not certified/eligible to be paid for this procedure/service on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. The rules also say that only an entity enrolled with 
Medicare as an OTP can bill these codes. 
 
We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the take-home supply of Methadone have not been met. Therefore, we decided that the 
Plan does not have to pay for the take-home supply of Methadone (G2078) provided on September 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2752) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that you were only allowed 
two crowns per year. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 19, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown (D2752) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal tooth #29 
(D2750), and core buildup, including any pins when required tooth #29 (D2950) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you broke a crown and received a temporary 
crown and a permanent crown a couple of days later. You also say that the crown was not covered because it 
was a few days short of the 2 years allowed. 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 items or services was exhausted on date of service June 11, 2022, 
processing before this claim for the service at issue. Therefore, we decided that the Plan does not have to pay 
for a crown - porcelain fused to high noble metal tooth #29 (D2750), and core buildup, including any pins 
when required tooth #29 (D2950) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the left hearing aid (V5257) provided on May 13, 
2022. 
 
You asked the Plan to pay in full for the left hearing aid. You say that you were told you could get this hearing 
aid, but you cannot pay the bill because you are on disability. The Plan denied your request. The Plan says the 
maximum benefit has been met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays a 
$2,000 maximum allowance toward the cost of a hearing aid(s) per ear every 3 years. 
 
We looked at this the file and the Plan's rules. The record shows that you received a left hearing aid (V5257) on 
July 19, 2019, in which the Plan paid $1,500. Your claim from May 13, 2022, was processed to pay $500 for 
the left hearing aid. Since you received a hearing aid within three years of the date of service, you had a 
remaining balance to be used of $500. Therefore, the Plan paid $500 for the left hearing aid and denied $1,500 
as the benefit maximum has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the left hearing aid have not been met. Therefore, we decided that the Plan does not have to pay in 
full for the left hearing aid (V5257) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 19, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the visit was an emergency because you broke 
your tooth. 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 limited oral evaluation was exhausted on the date of service of July 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5253) October 1, 2022. 
 
You asked the Plan to pay for a hearing aid (V5253). You say that you were advised that you have hearing aid 
coverage. The Plan denied your request. The Plan says hearing aids are covered only if purchased from a Plan 
hearing vendor provider. The provider you used is not a Plan hearing vendor provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use a Plan hearing vendor provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5253) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5253) October 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not aware the primary care provider was 
required to authorize the services. The Plan denied your request. The Plan says there is no authorization on file 
for the services rendered. 
 
 
 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 September 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had an 
episode when you were visiting your daughter and an ambulance was called. You also say that after treatment 
you became more alert, wanted to go back to your home and refused the transfer to the hospital. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to receive 
the care needed. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in another setting such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has no documented rehab or extensive therapy needs. While the enrollee 
may benefit from physical or occupational therapy, their needs can be provided in a lower intensity and 
alternate level of care such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was an emergency because you broke your 
tooth. 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 the date of service of July 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on November 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental exam and oral x-rays provided on June 27, 2022, to 
July 12, 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 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 dental exam and oral x-rays provided on June 27, 2022, to July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an out-of-network acupuncture visit. 
 
You asked the Plan to reimburse you for an out-of-network acupuncture visit. You say that you want the full 
80% reimbursement, like your previous visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for acupuncture for chronic low back pain. The allowed amount of this service is $37.55, resulting 
in a 20% coinsurance, your responsibility was $7.51. Meaning the amount that you were reimbursed was 
correct. 
 
This item/service falls within the acupuncture for chronic low back pain 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 reimburse you for an out-of-network acupuncture visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue conditioning - mandibular (D5851) provided on 
November 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan 
denied your request. The Plan says the denied services are not covered 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 tissue 
conditioning - mandibular (D5851) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 23, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this should be covered. 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 periodontal maintenance (D4910) provided on November 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a fractured pelvis. You say that you need 
rehab, and you cannot walk without assistance. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary, and you can safely receive the care you need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and do not require physician supervision or any acute 
rehab nursing needs. While you can benefit from physical and occupational therapy, your needs can be safely 
provided in an alternate level of care such as a skilled nursing facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 30, 
2022. 
 
You asked the Plan to pay for procedure code 99232. The Plan denied your request. The Plan says payment for 
code 99232 is bundled into payment for code 99221. 
 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 99232 is a column II code to column I code 99221. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99232 billed for date of service July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on September 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
 
 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 chiropractic services provided on September 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
August 22, 2022. 
 
You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you would like this claim to 
be reprocessed for payment. The Plan denied your request. The Plan says the documentation received does not 
indicate that the enrollee received the screening study for one of the risk categories of a family history of 
abdominal aortic aneurysm, a man aged 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or other 
risk factors recommended. 
 The Plan follows Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who meet the criteria listed in the Medicare 
rules section of this letter. 
 
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 ultrasound of the abdominal aorta. Our 
reviewer says that the criteria for coverage for this service have not been met. Our physician reviewer found the 
dictated history was "65-year-old male for screening for abdominal aortic aneurysm (AAA)". Our physician 
reviewer also found that the dictated history in this case, as it appears in the report, does not satisfy the Centers 
for Medicare and Medicaid Services (CMS) rules for the exam. 
 
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 ultrasound of the abdominal aorta have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on August 22, 
2022.