Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from December 31, 2021, to January 6, 2022.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay this copayment because of Covid. 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 $250 copayment per day for days 1 to 5 for inpatient hospital care. 

You have been asked to pay a $250 copayment per day for days 1 to 5 and $0 per day for any additional Medicare-covered days for inpatient hospital care. You are being charged $250 for 5 days which equals to $1,250. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from December 31, 2021, to January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on July 7, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that you have an 
annual maximum benefit of $1,500 and this cleaning falls within the annual maximum and should be covered 
under this benefit. The Plan denied your request. The Plan says the 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 the 
comprehensive periodontal evaluation (D0180) provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge (99217) provided on February 23, 2021.

You asked the Plan to pay for the evaluation and management service. You say that the claim should be paid. You also say that the claim was filed timely. The Plan denied your request. The Plan says the claim was not filed timely.

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 this claim for the evaluation and management service was not filed until May 20, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. The record also shows that there is no indication on the claim in this case that it was a corrected claim. As a result, the claim was processed correctly. Therefore, we decided that the Plan does not have to pay for the observation care discharge (99217) provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335 and 81355.

You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare guidelines.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.


We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335 and 81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 6, 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 08, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 August 21, 2019. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure (D7999) provided on 
December 2, 2021. 
 
You asked the Plan to pay for an oral surgery procedure. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the requested service is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an unspecified oral surgery 
procedure (D7999) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging 
(D0210), and scaling in presence of generalized moderate or severe gingival inflammation (D4346), provided 
by an out-of-network provider on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the office would verify your 
coverage. 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 comprehensive oral evaluation (D0150), intraoral imaging (D0210), and scaling in presence of 
generalized moderate or severe gingival inflammation (D4346), provided by an out-of-network provider on 
June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), topical application of fluoride 
(D1208), and bitewing x-rays (D0274) provided on June 15, 2022. 
 
You asked the Plan to pay for the pulp vitality tests, topical application of fluoride, and bitewing x-rays. You 
say that if you had known the treating provider did not accept your insurance, you would not have gone to the 
appointment. The Plan denied your request. The Plan says the pulp vitality tests, and topical application of 
fluoride are not covered dental benefits. The Plan also says that you met your benefit limit for bitewing x-rays 
on June 1, 2022. 
 
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 pulp vitality tests (D0460) and 
topical application of fluoride (D1208) are not among those covered under this benefit. The contract also 
clearly states that bitewing x-rays are limited to one of either codes D0270, D0272, D0273, or D0274 once 
every six months. The record shows that you received bitewing x-rays on June 1, 2022, and your bitewing x-
rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the pulp vitality 
tests (D0460), topical application of fluoride (D1208), and bitewing x-rays (D0274) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an appointment with a new dentist and 
the exam 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 the date of service of July 30, 2020. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and panoramic radiographic 
image (D0330) provided on June 17, 2022, to June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an infection and the provider told you it 
had spread into your jaw. 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. This benefit includes the 
requested limited oral evaluation (D0140) but is limited to one procedure per plan year and panoramic 
radiographic image (D0330) but is limited to one procedure every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested limited oral evaluation (D0140) and panoramic radiographic image 
(D0330) was exhausted on date of service May 25, 2022. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation (D0140) and panoramic radiographic image (D0330) provided on June 17, 2022, 
to June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on April 14, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were told that you 
could have two dental visits per year, but this charge was denied. 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 March 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 16, 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 January 5, 2022, and July 
27, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist for a consultation and 
second opinion. You say that you were charged for a comprehensive oral evaluation and you disagree. 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 March 31, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a recement crown (D2920) for tooth #30 provided on April 
25, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was only a minor procedure, 
and you would like for it to be covered. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because restorative and major dental care services are not covered by the 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 a 
recement crown (D2920) for tooth #30 provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to a new dentist, and you did not 
know the dental rule. 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 22, 2020. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewing x-rays (D0277) provided on June 23, 2022. 
 
You asked the Plan to pay for x-rays. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says vertical bitewing x-rays (D0277) are not covered by the enrollees 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 pay for vertical 
bitewing x-rays (D0277) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the lower partial denture 
(D5214) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that no one told you that your dental maximum was 
met, and you would like the dental services covered. The Plan denied your request. The Plan says your benefit 
maximum for the yearly dental services 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. On June 14, 
2022, the Plan paid $173 and on June 16, 2022, the Plan paid $577; therefore, the yearly dental benefit 
maximum of $750 ($173 paid + $577 paid) was met. The record shows your yearly dental benefit maximum 
was exhausted on the date of service of June 16, 2022. Therefore, we decided that the Plan does not have to pay 
for the panoramic x-ray (D0330) and the lower partial denture (D5214) provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The Plan denied your request. The Plan says the 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 your medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival flap procedure including root planing (D4241) 
provided on March 1, 2022. 
 
You asked the Plan to pay for the gingival flap procedure including root planing (D4241). You say that you 
want to appeal the denied claim. The Plan denied your request. The Plan says the 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 the 
gingival flap procedure including root planing (D4241) provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 3, 2022.

You asked the Plan to pay for procedure code 70480. You say that this was not a bundled charge. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for code 70450.

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 70480 is a column II code to column I code 70450. This claim 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 70480 billed for date of service May 3, 2022.