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

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063 x 13) 
and implant supported porcelain crowns (D6065 x 7). 
 
You asked the Plan to pre-approve the dental services. You say that you already received a service from your 
dentist. You say that you now need the implants to complete the services. The Plan denied your request. The 
Plan says dental implants and all associated services are excluded from coverage. 
 
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 abutment supported cast 
metal crowns and implant supported porcelain crowns are not among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pre-approve abutment supported cast metal crowns 
(D6063 x 13) and implant supported porcelain crowns (D6065 x 7).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable supplies (A0382) and oxygen (A0422) 
provided during a basic life support (BLS) ambulance transport on February 23, 2022. 
 
You asked the Plan to pay for the oxygen and supplies. You say that this transportation was medically 
necessary, and the patient needed oxygen.  The Plan denied your request. The Plan says it has paid for the BLS 
services, but there is no separate payment for the supplies and oxygen. 
 
The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for supplies and 
oxygen provided during an ambulance transport.  The payment for the ambulance mileage includes the costs 
for supplies and oxygen. Based on this information, we decided that Medicare rules for coverage of the oxygen 
and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the disposable 
supplies (A0382) and oxygen (A0422) provided during a basic life support (BLS) ambulance transport on 
February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (code D6192) for tooth #6. 
 
You asked the Plan to pre-approve dental implant. You say that the Plan's denial is in error and this should be 
approved. The Plan denied your request. The Plan says this service is covered by the Plan's dental benefits; 
however, your benefit for 8 covered dental implants per year has 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. The Plan covers up to 8 dental 
implants per year.  
 
We looked at this the file, the Plans rules, and Medicare rules. The Plan approved coverage for 8 dental 
implants; therefore, the benefit for dental implants has been exhausted. Based on this information, we decided 
that the Plan's rules for coverage of dental implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dental implant (code D6192) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental bone grafts (codes D4263 and D4264). 
 
You asked the Plan to pre-approve dental bone grafts. You say that you are appealing this denial. The Plan 
denied your request. The Plan says these services 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 
dental bone grafts (codes D4263 and D4264).
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 14, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you 
were clear about your dental needs when you signed up for the Plan and were assured there would be no 
waiting period before the Plan covered dental expenses. The Plan denied your request. The Plan says implant 
services are excluded from coverage. 
 
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 14, 2022.   
Your complaint about potentially being provided incorrect or incomplete information when you signed up for 
the Plan 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic crown (D6242), and a retainer crown (D6752), 
provided by an out-of-network provider on January 26, 2022. 
 
You asked the Plan to pay for a pontic crown and a retainer crown. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
crown (D6242), and a retainer crown (D6752), provided by an out-of-network provider on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth x-ray (D0330), and a comprehensive oral 
evaluation (D0150), provided by a participating provider on February 10, 2022. 
 
You asked the Plan to pay for a full mouth x-ray and a comprehensive oral evaluation. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0330 and 
D0150 have already been met and 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 a full mouth 
x-ray once every five years and one comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0330 were 
previously provided on August 19, 2020. Based on this information, we decided that the Plan's rules for 
coverage of a full mouth x-ray and a comprehensive oral evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for a full mouth x-ray (D0330), and a comprehensive oral evaluation 
(D0150), provided by a participating provider on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy services (96413, 96375, 96417, 96367, 
and 96415) provided on January 18, 2022. 
 
You asked the Plan to pay for codes 96413, 96375, 96417, 96367, and 96415. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
supported. 
 
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 96413 is Chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported 
in the medical record. Specifically, the medical records do not include a start time to support that chemotherapy 
administration up to 1 hour was performed.  
 
We have also confirmed that codes 96375, 96417, 96367, and 96415 are add-on codes and are not payable as 
the primary code, 96413, is not payable. Based on this information, we decided that Medicare rules for 
coverage of codes 96413, 96375, 96417, 96367, and 96415 have not been met. Therefore, we decided that the 
Plan does not have to pay for the chemotherapy services (96413, 96375, 96417, 96367, and 96415) provided on 
January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of a broken tooth (D5640) provided on June 
10, 2021. 
 
You asked the Plan to pay for the replacement of a broken tooth. You say that you received a flyer from the 
Plan listing what is covered for dental care excluding a $50 copay, and 50% coinsurance. You also say that you 
believe the Plan owes you $48 for this service. The Plan denied your request. The Plan says dental care copays 
and coinsurances are not reimbursable through the Wellness Wallet 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.   
We looked at the file and Medicare rules. The Plan offers a supplemental benefit for dental services, and also 
offers a benefit for various other services. The benefit does not cover dental services. 
Based on this information, we decided that the Plan's rules for coverage of the replacement of a broken tooth 
have not been met. Therefore, we decided that the Plan does not have to pay for the replacement of a broken 
tooth (D5640) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic (D2740) for tooth 20. 
 
You asked the Plan to pre-approve a crown. You say that a full coverage crown is the only option to save the 
enrollee's tooth. The Plan denied your request. The Plan says that the enrollee does not meet criteria for a 
crown. 
 
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. We requested the Plan provide diagnostic quality x-rays for review.  We have 
only received photocopies which are not sufficient to review. Thus, we are unable to verify the Plans denial of 
the crown based on medical necessity. Therefore, we decided that the Plan has to pre-approve a crown - 
porcelain/ceramic (D2740) for tooth 20.  
 
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 dental services provided by an opt-out provider on December 
2, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until August 1, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided by a participating 
provider on January 18, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that the Plan should pay for this. The Plan denied 
your request. The Plan says D4921 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 gingival 
irrigation (D4921) provided by a participating provider on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided February 8, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you weren't informed your dentist 
was going to perform a procedure that would not be covered. 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 
intraoral - complete series of radiographic images (D0210) provided February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve the SNF services. You say that the SNF stay should be approved. The Plan 
denied your request. The Plan says that the enrollee does not meet the CMS criteria for skilled nursing level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 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 SNF services. Our reviewer says 
that you do not qualify for SNF coverage. Our physician reviewer found that the enrollee does not have 
documented skilled nursing needs or skilled therapy needs. The enrollees care needs can be provided at a lower 
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 the SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on 
Spetember 1, 2021, through September 10, 2021 and billed with Patient Driven Payment Model (PDPM) code 
OKXD. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with a valid PDPM 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that under the new Patient-Driven Payment Model 
(PDPM), which is effective for services provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under the revised model. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Specifically, this claim has not been billed with a valid PDPM 
code. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services 
provided on Spetember 1, 2021, through September 10, 2021 and billed with Patient Driven Payment Model 
(PDPM) code OKXD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the electronic connection. You say that this electronic connection is 
medically necessary for the enrollee's to use the power wheelchair and associated accessories. The Plan denied 
your request. The Plan says there is no medical need to control power options through joystick. 
 The Plan follows Medicare rules. Medicare rules say that the requested electronic connection is subject to the 
criteria listed 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 the electronic connection. Our reviewer 
says that the requested electronic connection is not medically reasonable and necessary. Our physician reviewer 
found the patient is a 69-year-old female with past medical history of cervical myelopathy. There is no clinical 
documentation to support need for electronic connection between the power function through the joystick. It is 
documented that patient has 4/5 motor strength and although with arthritis of bilateral shoulders there was no 
specific documentation to preclude using the power function with its own switch. 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection between wheelchair controller and 2 or more 
power seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided September 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed is not separately payable. 
 
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 83789 is not supported in the medical record. Specifically, this code is inclusive to 
codes 80307 and G0480 which were already approved. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (83789) provided September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93970) provided on August 30, 2021. 
 
You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 93970 is not supported in the record. Specifically, the documentation submitted 
indicates that the enrollee was registered inpatient on the billed date of service. This claim was not billed with 
the correct POS code. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does not have to pay for the extremity study 
(93970) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nursing facility care provided on October 8, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Nursing facility care. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 Nursing facility care provided on October 8, 2021 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on August 26, 2020. 
 
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 procedure code 97110 is not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the physical therapy services rendered on August 26, 2020.