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

 
We decided that the Plan does not have to pre-approve 48 additional routine transportation (A0120). 
 
You asked the Plan to pre-approve additional trips. You say that you need more transportation for your 
appointments. The Plan denied your request. The Plan says additional transportation beyond the allowed 48 
one-way trips are not covered. 
 
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 48 one-way 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 48 additional routine transportation (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on November 18, 2021, and 
restorative procedures (D2999 x 6), and prophylaxis (D1110) provided on November 19, 2021. 
 
You asked the Plan to pay for a crown, restorative procedures, and prophylaxis. You say that you have seen 
this dentist for twenty years. You also say that you were never told that you could not use a dentist outside the 
United States. The Plan denied your request. The Plan says these dental services are not covered when 
performed outside the United States. 
 
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 crown 
(D2740) provided on November 18, 2021, and restorative procedures (D2999 x 6), and prophylaxis (D1110) 
provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted craniofacial and maxillofacial procedure (21299) 
provided on January 12, 2022. 
 
You asked the Plan to pay for the unlisted craniofacial and maxillofacial procedure (21299). You say that the 
medical records support CPT code 21299. The Plan denied your request. The Plan says the billed procedure 
code 21299 is not a covered ambulatory surgical center 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 21299 is unlisted craniofacial and maxillofacial 
procedure. 
 
  We find that CPT code 21299 is not supported in the medical record. Specifically, CPT code 21299 is not a 
covered service at an ambulatory surgical center. Based on this information, we decided that Medicare rules for 
coverage of the unlisted craniofacial and maxillofacial procedure (21299) have not been met. Therefore, we 
decided that the Plan does not have to pay for the unlisted craniofacial and maxillofacial procedure (21299) 
provided on January 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of elbow (73080) provided on November 11, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be paid. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the x-ray of elbow (73080) provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services provided on March 31, 2021. 
 
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says these services were not 
billed with the correct modifier required for payment.  
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 looked at the file and Medicare rules. An independent laboratory may not bill for the technical 
component of a physician pathology service furnished to a hospital inpatient or outpatient. No modifier was 
included to indicate that the professional component is the only service being billed. Based on this information, 
we decided that Medicare rules for coverage of the laboratory testing services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory testing services provided on March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 222 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
your treatments 3 times per week. You also say that this benefit is your only option. The Plan denied your 
request. The Plan says additional transportation beyond the 72 allowed per year are not covered. 
 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 72 one-way 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 222 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230), and unspecified 
preventive service (D1999) provided on January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised your fee for the appointment 
would be $60.90. You say that the nurse did a radiographic image without your permission. You also say that 
the services should be covered. The Plan denied your request. The Plan says the claim was processed 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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for the initial 
periapical x-ray that you received on the date of service in this case. Additionally, the unspecified preventive 
service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the additional periapical x-ray (D0230), and unspecified preventive service (D1999) provided on January 
26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy on tooth #9 and 10 (D3310), 
prefabricated posts for tooth #9 and 10 (D2954), a crown on tooth #9 and 10 (D2750), and a resin-based 
composite filling (D2392). 
 
You asked the Plan to pre-approve endodontic therapy, posts, crown, and a filling. You say that these services 
are medically necessary. The Plan denied your request. The Plan says endodontic therapy (D3310), 
prefabricated posts (D2954), a crown (D2750), and a resin-based composite filling (D2392) are not covered by 
the Plan's 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 
endodontic therapy on tooth #9 and 10 (D3310), prefabricated posts for tooth #9 and 10 (D2954), a crown on 
tooth #9 and 10 (D2750), and a resin-based composite filling (D2392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift. 
 
You asked the Plan to pay for a stair lift. You say that you disagree with the plan's decision. The Plan denied 
your request. The Plan says the item received is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy services. 
 
You asked the Plan to pre-approve the requested services. You say that the device is medically necessary to 
monitor the enrollee's lymphedema. The Plan denied your request. The Plan says that the procedure is 
unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee had a left mastectomy for preinvasive disease 2003, and a right mastectomy 
with sentinel node biopsy in 2022. Bioimpedance spectroscopy (BIS) is a more accurate method of identifying 
which breast cancer survivors will need compression intervention compared with tape measurement (TM) to 
prevent chronic lymphedema, according to findings from a study published in Lymphatic Research and 
Biology. Specifically, results from the PREVENT study (NCT02167659) showed that among those who 
received compression intervention after early lymphedema detection, only 7.9% of patients who were assessed 
through BIS developed chronic lymphedema. The documentation does support that the requested services are 
medically reasonable and necessary in this case. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve bioimpedance spectroscopy services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service (D9310) and removal of impacted tooth 
(D7240) on November 9, 2021, and November 16, 2021. 
 
You asked the Plan to pay for a diagnostic service (D9310) and removal of impacted tooth (D7240). You say 
that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the services 
provided, a diagnostic service (D9310) and removal of impacted tooth (D7240) are not covered services as 
indicated on the chart in the EOC on pages 108-110. 
 
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 
diagnostic service (D9310) and removal of impacted tooth (D7240) on November 9, 2021, and November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a periapical x-ray on tooth #5 (D0220) and 
additional periapical x-rays on tooth #6 and 7 (D0230) provided on February 22, 2022. 
 
You asked the Plan to waive the deductible for x-rays. You say that the provider did not inform you that you 
were going to be charged for the x-rays. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 there is a $100 deductible which applies to class 2 basic services, including 
periapical x-rays.  
 
The item or service you asked the Plan to waive the deductible for falls within the Dental Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 
deductible which applies to class 2 basic services, including periapical x-rays. This cost sharing is a contractual 
obligation that had not been met at the time x-rays was received on February 22, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for a periapical x-ray on tooth #5 (D0220) and additional 
periapical x-rays on tooth #6 and 7 (D0230) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete 
intraoral x-ray (D0210) provided on February 15, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that you disagree with the denial for dental 
services. The Plan denied your request. The Plan says these services are covered by the Plan's dental benefits; 
however, your benefits for one comprehensive oral evaluation (D0150) every three calendar years and one 
complete intraoral x-ray (D0210) every five calendar years have been exhausted. 
 
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 one 
comprehensive oral evaluation (D0150) every three calendar years and one complete intraoral x-ray (D0210) 
every five calendar years.  
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation provided on August 5, 2021; therefore, the benefit for a comprehensive oral 
evaluation has been exhausted. The record also shows the Plan paid for a complete intraoral x-ray provided 
on July 27, 2021; therefore, the benefit for a complete intraoral x-ray has been exhausted. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete intraoral x-ray 
(D0210) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty (D7321). 
 
You asked the Plan to pre-approve the alveoloplasty. You say that  The Plan denied your request. The Plan says 
alveoloplasty (D7321) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
alveoloplasty (D7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 4), a 
comprehensive periodontal evaluation (D0180), and drugs dispensed for home use (D9630) provided on 
February 22, 2022. 
 
You asked the Plan to pay for periodontal scaling, evaluation, and drugs. You say that you disagree with the 
denial for dental services. You also say that you cannot pay the $631 bill as you are on disability. The Plan 
denied your request. The Plan says a comprehensive periodontal evaluation (D0180) and drugs dispensed for 
home use (D9630) are not covered by your routine dental benefits. The Plan also says that periodontal scaling 
and root planing (D4341) is covered by your routine dental benefits; however, when received by an out-of-
network provider you might be billed for any amount greater than what the Plan pays. 
 
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 record shows you 
received services from an out-of-network provider. According to the EOC, you might be 
billed by the provider for any amount greater than what the Plan pays when seen by an out-of-network 
provider. Though the Plan offers a dental benefit in excess of Medicare coverage, a comprehensive periodontal 
evaluation (D0180) and drugs dispensed for home use (D9630) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 4), 
a comprehensive periodontal evaluation (D0180), and drugs dispensed for home use (D9630) provided on 
February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for extractions of tooth #30 and 31 
(D7210) provided on February 4, 2022. 
 
You asked the Plan to increase the reimbursement for extractions. You say that you expected to be refunded 
$150 for the two extractions. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 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 70% 
coinsurance for an out-of-network extraction. 
  
The record shows you received the extractions from an out-of-network provider. The record also shows the 
Plan paid $65.66 for the extractions, which was reimbursed to you. You have been left responsible for $153.24, 
which is less than 70% coinsurance of the allowed amount for extractions. Therefore, you have been 
reimbursed the correct amount ($218.90 allowed amount - $153.24 coinsurance = $65.66). Extractions fall 
within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to increase the reimbursement for 
extractions of tooth #30 and 31 (D7210) provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you don't understand why the dentist is using this 
code. 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 pre-approve core 
buildup, including any pins when required (D2950).
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 IRF care is medically necessary because you need 
rehab for your leg. The Plan denied your request. The Plan says IRF care is not medically necessary and your 
needs can be provided safely in a less intensive setting, such as at 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 that while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services an IRF would provide.  
 
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 limited oral exam (code D0140) you received on 
December 7, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you had to go to the dentist because you had 
a broken tooth that needed to be evaluated. The Plan denied your request. The Plan says you had already 
exhausted your benefit for this service for 2021. 
 
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's rules state that only 
one limited oral exam (code D0140) is covered per year.  You already received a covered limited oral exam on 
March 10, 2021, so you were not eligible for another one on the date of service in question in this appeal.  This 
limitation applies regardless of the reason for or the necessity of the exam. 
 
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 
limited oral exam (code D0140) you received on December 7, 2021.