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

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and resin-based composite 
(D2392) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for resin-based composites were exhausted on date of service April 13, 2022, and May 18, 
2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) and resin-
based composite (D2392) provided on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on October 20, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this item was used outside the home and is non-
covered. 
 
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 item 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 pay for a pneumatic compression device (E0673, E0675) provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on October 17, 2022. 
 
You asked the Plan to pay for the CGM. You say that you are requesting a reconsideration of payment for the 
CGM. The Plan denied your request. The Plan says the enrollee does not require insulin three or more times 
daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic 
continuous glucose monitor (CGM) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), cone 
beam CT capture and interpretation with field of view of one full dental arch (D0366), pulp vitality tests 
(D0460), incomplete endodontic therapy; inoperable, unrestorable or fractured tooth  (D3332), and consultation 
- diagnostic service provided by dentist or physician (D9310) provided on September 21, 2022. 
 You asked the Plan to pay for the dental services. You say that the office personnel should have called your 
insurance before the services were rendered. The Plan denied your request. The Plan says your benefit for the 
limited oral evaluation - problem focused (D0140) has already been exhausted. The Plan says the dental 
services represented by codes D0366, D0460, D3332 and D9310 are not covered by the Plans 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 the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
September 13, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), cone beam CT capture and interpretation with field of view of one full dental arch 
(D0366), pulp vitality tests (D0460), incomplete endodontic therapy; inoperable, unrestorable or fractured tooth  
(D3332), and consultation - diagnostic service provided by dentist or physician (D9310) provided on 
September 21, 2022. 
  
Your complaint about the providers office being incompetent is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36227 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 36227. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 36227 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 36227 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 36227 billed for date of service November 4, 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 December 27, 
2022 
 
You asked the Plan to pay for a limited oral evaluation. You say that you do not understand why this was not 
paid. The Plan denied your request. The Plan says the rendered dental 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 a limited 
oral evaluation (D0140) provided on December 27, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on 
December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this 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. 
 
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 December 8, 2022. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on December 8, 2022.
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 October 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the service 
was urgent and the emergency care that was provided by the emergency medical services team was necessary. 
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 October 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 October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on November 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not a covered benefit when provided by an OON 
provider. 
 
 
 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 wound care services provided on November 7, 
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 a custom fabricated abutment (D6057), and an implanted 
supported crown (D6065), provided on July 28, 2022. 
 
You asked the Plan to pay for D6057 and D6065. You say that you do not understand why this is not covered. 
The Plan denied your request. The Plan says these services are not covered. 
 
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 a custom 
fabricated abutment (D6057), and an implanted supported crown (D6065), provided on July 28, 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 December 22, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you needed this evaluation. The Plan 
denied your request. The Plan says the rendered dental exam 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 a limited 
oral evaluation (D0140) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261), ear molds (V5265 x 2), and the 
dispensing fee (V5160) provided on November 15, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for the 
items provided in this case. 
 
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.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that there is a hearing aid 
benefit of $500 for both ears combined every three years. The Plan stated that you have exhausted the 
allowable benefit for these items as you previously received hearing aid repair services on April 8, 2021 and 
October 21, 2021 that were paid for by the Plan in the amount of $500, less than three years prior. Therefore, 
you have exhausted the allowable benefit for the items provided in this case.  Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261), ear molds (V5265 x 2), 
and the dispensing fee (V5160) provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services (99238) provided on September 
15, 2022. 
 
You asked the Plan to pay for the hospital discharge services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the code billed cannot be paid more than once for the 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99238 is hospital discharge day management. 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, only one hospital discharge 
day management service is payable per patient per hospital stay. This code was already paid once on October 6, 2022. Based on this information, we decided that Medicare rules for coverage of the hospital discharge services 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge services 
(99238) provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), and a 
complete series of radiographic images (D0210), provided on October 23, 2022, to November 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware this provider was out-
of-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation (D0150), 
and a complete series of radiographic images (D0210), provided on October 23, 2022, to November 8, 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 December 2, 
2022. 
 
You asked the Plan to pay for the dental service. You say that it was an emergency to get the dental services 
done because you had a surgery done. 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 February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 2, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214) provided on October 10, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan stated that you have exhausted the allowable benefit for 
the service provided in this case. The Plan contract states that supplemental coverage is provided for routine 
chiropractic and routine acupuncture visits combined. A maximum of 12 visits are covered per calendar year. 
The Plan has not provided substantive evidence that demonstrates you previously received 12 routine 
chiropractic or acupuncture services that were paid for by the Plan. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the office visit (99214) 
provided on October 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on October 12, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that you were not aware that this provider and 
lab were out-of-network. This should be covered, you cannot afford this bill. The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory drug testing 
provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), and palliative (emergency) 
treatment, minor procedure (D9110) provided on January 14, 2023. 
 
You asked the Plan to pay for limited oral evaluation and palliative (emergency) treatment. You say that this 
should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
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 limited 
oral evaluation (D0140), and palliative (emergency) treatment, minor procedure (D9110) provided on January 
14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth or exposed root (D7140) 
and the upper partial denture (D5211) provided on December 5, 2022. 
 
You asked the Plan to pay for this dental item/service. 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 item/service were received 
from an out-of-network provider and are not covered by your supplemental benefits. Additionally, an upper 
partial denture 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. 
 
 The record shows you received the dental item/service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the dental item/service provided are not covered under 
this benefit when received from an out-of-network provider. Additionally, an upper partial denture is not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of an erupted tooth 
or exposed root (D7140) and the upper partial denture (D5211) provided on December 5, 2022.