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

 
We decided that the Plan does not have to pay for the custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) provided February 10, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that this 
service was necessary for your health. The Plan denied your request. The Plan says this service is not covered 
under your 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 the 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) provided February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 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 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, a cardiovascular risk assessment panel, 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 rendered on September 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation services. 
 
You asked the Plan to pre-approve additional transportation services. You say that you do not drive and do not 
have anyone who can provide transportation for you. You also say that you depend on the transportation 
benefit to see your doctors. The Plan denied your request. The Plan says you have used 49 transportation trips 
of your transportation benefit and have 1 trip remaining before your transportation benefit is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way, non-emergency trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 14, 2022. 
 
You asked the Plan to pay for the medical services. You say that the member revoked hospice on February 5, 
2022, so the Plan should pay for these services. The Plan denied your request. The Plan says Original Medicare 
is responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9946). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you are having a hard time with chewing 
food. You say that you are constantly biting yourself and bleeding. You also say that your front teeth are 
cracked. The Plan denied your request. The Plan says an occlusal guard 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 Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard 
(D9946).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the canal preparation and fitting of preformed dowel or post 
(D3950), prefabricated post and core in addition to crown (D2954), resin-based composite (D2332), or pay 
more for the crown (D2750) provided on October 11, 2021, and October 20, 2021. 
 
You asked the Plan to pay for the canal preparation and fitting of preformed dowel or post, prefabricated post 
and core, resin-based composite, and to pay more for the crown. You say that you changed plans during the 
2021 benefit year, and a decision was made to combine the dental reimbursement amounts from both plans to 
total an amount of $3,250 for the 2021 contract year. The Plan denied your request. The Plan says the annual 
limit allowed by your 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 $2,000 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you 
are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit on October 20, 2021, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the canal preparation and fitting of preformed dowel or post 
(D3950), prefabricated post and core in addition to crown (D2954), resin-based composite (D2332), or pay 
more for the crown (D2750) provided on October 11, 2021, and October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on January 5, 2022. 
 
You asked the Plan to pay for the crown. You say that you signed up with the Plan to pay an extra $12 per 
month for a dental package to go into effect in 2022 with the new coverage. You also say that your tooth broke, 
and you needed to have crown work done. The Plan denied your request. The Plan says on this date of service 
you only had the mandatory supplemental dental benefit from the Health Plan. The Plan also says that this 
procedure is not covered under your dental 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 pay for the crown 
(D2750) provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed on November 20, 2021. 
  You asked the Plan to pay for procedure code 99053. You say that the enrollee was seen twice on the same date 
of service at two different locations and by two different providers. You say that the notes should be reviewed, 
and the claim reprocessed accordingly for payment. The Plan denied your request. The Plan says procedure 
code 99285 has been overturned and procedure code 99053 remains denied as bundled services are not eligible 
for separate reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed on November 20, 2021.
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 requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 the member does not have intensive or complex rehabilitation needs requiring physiatry oversight. Rehabilitation of a pelvic fracture is done with oral pain medications and weight bearing to 
the degree the fracture permits. Her fracture is stable, and she is WBAT. Without intensive or complex 
rehabilitation needs she does not need physiatry oversight. Her rehabilitation needs are quite routine. 
 
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 two crowns (D2740 x2) provided on December 13, 2021. 
 
You asked the Plan to pay for the crowns. The Plan denied your request. The Plan says your benefit period 
maximum has been reached. 
 
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 Plan offers a benefit maximum of 
$1,000 each calendar year for comprehensive services. The contract says you are responsible for amounts 
beyond the benefit limit. The record shows that you met the annual maximum benefit while reprocessing the 
claim for December 13, 2021, and your annual maximum benefit has been exhausted.  
 
Therefore, we decided that the Plan does not have to pay for the two crowns (D2740 x2) provided on 
December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 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 January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided from November 22, 
2021, through February 19, 2022. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says documentation required for payment is 
missing. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Though a packing 
slip was included, it was not signed by the enrollee confirm receipt, nor was a delivery confirmation from a shipper included. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies 
provided from November 22, 2021, through February 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the white filling on a back tooth, 3 surfaces, (D2393) 
provided on February 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist does not do amalgam fillings. You 
say that it is on the front side of the tooth that shows when you talk or smile. You also say that your dentist 
advised that amalgam filling is not standard practice. The Plan denied your request. The Plan says the white 
filling on a back tooth is not a covered dental service. 
 
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 white filling on a back tooth is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the white 
filling on a back tooth, 3 surfaces, (D2393) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided by 
a participating provider on March 24, 2022. 
 
You asked the Plan to pay for dental services. You say that this was emergency dental work. The Plan denied 
your request. The Plan says the rendered dental 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 the 
treatment of root canal obstruction (D3331) provided by a participating provider on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on February 10, 
2022. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
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 record does not contain relevant medical records which support 
medical necessity for the supplies provided in this case. The documentation does not indicate that the enrollee 
performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or 
requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 14, 2022. 
 
You asked the Plan to pay for the testing services. You say that the code is supported as noted. The Plan denied 
your request. The Plan says the documentation does not support the coding criteria. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. Specifically, the records do not show that 8 
drug classes were tested.  Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on 
February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 9, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you are entitled to a partial payment under your 
plan because this was relayed to you when you contacted customer service. The Plan denied your request. The 
Plan says services performed by an OON provider are not covered because your healthcare plan does not have 
OON benefits. The Plan also says that when you contacted the Plan, you were advised that services rendered 
OON would not be covered, and the Plan found there are 101 in-network general dentists within a 30-mile 
radius of your home address. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on March 9, 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 comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on January 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that this claim was submitted multiple times. The 
Plan denied your request. The Plan says this claim was received after the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until February 11, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
as 81404 and 81479 provided on March 3, 2021.  
You asked the Plan to pay for the genetic testing. You say that say the medical records provided support the 
necessity of the services in dispute. 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 documentation submitted indicates the cardiovascular genetic 
screening panel was initiated by the laboratory and not by the treating physician nor following a consultation or 
evaluation by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the cardiac risk assessment genetic screening testing coded as 81404 and 81479 provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a splint extra-coronal (D4323) provided by an out-of-
network provider on January 19, 2022. 
 
You asked the Plan to pay for a splint extra-coronal. You say that you had a broken tooth and needed these 
services. The Plan denied your request. The Plan says the rendered dental work 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 Plan's 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 splint 
extra-coronal (D4323) provided by an out-of-network provider on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power operated vehicle (K0812) provided on September 6, 
2021, by an online retailer not enrolled in the Medicare program. 
 
You asked the Plan to pay for a power operated vehicle. You say that the provider at issue is certified for 
Medicare. The Plan denied your request. The Plan says rules for payment have not been met because the 
provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a power operated vehicle (K0812) 
provided on September 6, 2021, by an online retailer not enrolled in the Medicare program.