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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), bitewing x-rays (D0274), panoramic x-ray (D0330), and filling (D2335) provided from January 26, 
2022, to January 31, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you called the plan and requested a list of 
participating dentists in your area. You also say that you also received a denial for the services you received. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
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 and the services are listed as covered, 
you pay 100% for dental services received out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), panoramic 
x-ray (D0330), and filling (D2335) provided from January 26, 2022, to January 31, 2022, by the out of network 
dentist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transforaminal epidural injection services 
(64484-RT, 64484-LT). 
 
You asked the Plan to pre-approve additional transforaminal epidural injection services. You say that these 
injections are medically necessary. The Plan denied your request. The Plan says these additional injections are 
not covered per Medicare coverage criteria for transforaminal epidural injection services. 
 
The Plan must follow Medicare rules. Medicare rules say that that no more than 2 transforaminal epidural 
injection services should be performed at a single setting. Based on this information and the injections that 
have already been approved for coverage, we decided that Medicare rules for coverage of additional 
transforaminal epidural injection services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional transforaminal epidural injection services (64484-RT, 64484-LT).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services rendered on August 3, 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 that procedure code 51999 is not separately payable. 
 
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. The Plan states that code 51999-80-59 is inclusive to approved code 44207-80; 
however, there are no active National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits for 
this code pair. The Plan has not provided any documentation or Medicare rules to support that code 51999 is 
not payable as billed. Therefore, we decided that the Plan has to pay for the surgical services rendered on 
August 3, 2021.  
 
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 the partial upper denture (D5213) provided on December 15, 2021. 
 
You asked the Plan to pay for the dental item. You say that you were covered before starting this process. You 
say that you feel you are not responsible for this bill. You say that your previous denture did not fit anymore. 
You say that the dentist never fixed it. You also say that you needed a new one. The Plan denied your request. 
The Plan says the partial upper denture is covered once every 5 plan years. The Plan also says that the 
frequency limit has been exceeded. 
 
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 the partial upper denture is covered 
once every 5 plan years, the frequency limit has been exceeded.  
 
Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213) provided on 
December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on December 23, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the crown. You say that your cost share of $1,152 for the crown is too 
much compared to the $332 that the Plan paid. The Plan denied your request. The Plan says your liability 
amounts were applied correctly. The Plan also says that cost sharing is a contractual obligation under the Plan 
and cannot be waived. 
 
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 a 50% 
coinsurance for the crown, plus the difference between the billed amount and allowed amount because the 
service was received OON. Therefore, we decided that the Plan does not have to pay more for the crown 
(D2740) provided on December 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 6) provided on 
August 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went in to get a tooth pulled. You say that 
the provider insisted you have x-rays done. You say that you advised you did not want x-rays if they were not 
going to be covered. You also say that you know you did not have this many x-rays. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray 
that you received on August 17, 2021. Therefore, we decided that the Plan does not have to pay for the 
periapical x-rays (D0220, D0230 x 6) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), panoramic 
x-ray (D0330), bitewing x-rays (D0274), prophylaxis (D1110), and intraoral x-rays (D0220 and D0230) 
provided on February 9, 2022 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay more for the comprehensive oral evaluation, panoramic x-ray, bitewing x-rays, 
prophylaxis, and intraoral x-rays. You say that you were informed by the provider's office that the provider 
accepts your insurance. You also say that you would like these services to be reviewed because you were 
misinformed by the office. The Plan denied your request. The Plan says you are financially liable for any cost 
sharing applied, including deductibles, coinsurance and copayments. The Plan also says that you are 
responsible for the contractual cost share. 
 
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, intraoral x-rays (D0220 and D0230) 
are not among those covered under this benefit. The contract clearly states that you are responsible for $10 
copayments for each of the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), bitewing x-rays 
(D0274), and prophylaxis (D1110). You are also responsible for the difference between the amount the plan 
paid and the billed amount because these services were received OON. Therefore, we decided that the Plan 
does not have to pay more for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), bitewing 
x-rays (D0274), prophylaxis (D1110), and intraoral x-rays (D0220 and D0230) provided on February 9, 2022 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) provided 
on October 14, 2021. 
 
You asked the Plan to pay for ambulance oxygen and oxygen supplies. You say that these services were 
medically necessary. The Plan denied your request. The Plan says they have agreed to pay for the ambulance 
services (A0428, A0425); however, the oxygen and oxygen supplies are always included in the base ambulance 
payment and are not separately billable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not make separate payment for items 
and services that are considered part of the general ambulance services. We looked at the file and Medicare rules. 
Based on this information, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies. Specifically, Medicare rules state that these services are included in the ambulance services rate and are not separately payable. Therefore, we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of lost or broken retainer (D8704) provided 
on November 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have a $1,000 dental allowance. You say 
that you only went in for a cleaning prior to this. You say that you did not use your full allowance. You also 
say that the cost of the bridge was only $250 and the plan should pay this in full. The Plan denied your request. 
The Plan says the replacement of lost or broken retainer 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 replacement of lost or broken 
retainer is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the replacement of lost or broken retainer (D8704) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided by an out-of-
network provider on January 18, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the services that were provided have been processed correctly. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a resin-based composite have been applied correctly. Therefore, we decided that the Plan does not 
have to pay for a resin-based composite (D2392) provided by an out-of-network provider on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two adjunctive procedures (D9999 x2) provided on 
November 1, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the adjunctive procedures. You say that prior to receiving these services, you 
contacted the Plan multiple times and were advised that it was alright to use this provider for your dental 
treatment. The Plan denied your request. The Plan says you received these services from a provider who chose 
not to receive Medicare funds. The Plan also says that you did not contact the Plan prior to receiving these 
services. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the two adjunctive procedures (D9999 x2) provided on November 1, 2021 by a 
Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics and gel pads. We decided that the Plan 
does not have to pre-approve gel pads.  
 
You asked the Plan to pre-approve the upgraded electronics and gel pads. You say that you are requesting 
reconsideration of the medical necessity of all the components of this K0861 required by the enrollee to meet 
her medical, functional and mobility needs throughout the day in her home. The Plan says that the upgraded 
electronics are not medically necessary the gel pads (K0108) do not serve a medical purpose and is not 
covered. 
 
We decided that the Plan has to pre-approve the upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve gel pads. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 upgraded electronics and gel pads. 
Our reviewer says that the Medicare criteria for the requested items/service were partially met. Our physician 
reviewer found the Group 3 Power wheelchair has three power functions. Therefore, the expandable controller 
(E2377) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) harness for upgrade to expandable controller (E2313) are medically necessary and meets requirements 
in LCD. There is no documentation to show that Gel pads K0108 serve a medical purpose thus don't meet 
criteria for coverage.  
 
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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics. The Medicare rules for coverage of gel pads have not been met. 
Therefore, we decided that the Plan does not have to pre-approve gel pads 
 
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 the two periodontal scalings and root planings (D4341 x2) 
provided on January 27, 2022. 
 
You asked the Plan to pay for the scalings and planings. You say that this is a cleaning and should be included 
on your plan. You also say that you believe the Plan should pay for these services. The Plan denied your 
request. The Plan says this service is 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, periodontal scaling and root planing 
(D4341) is not a preventive dental service and is not covered. Therefore, we decided that the Plan does not 
have to pay for the two periodontal scalings and root planings (D4341 x2) provided on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on October 14, 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 procedure code 23430-XS-RT 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. In this case, we have confirmed that code 23430 
is a column II code to column I code 23472. 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 the surgical services rendered on October 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0120). 
 
You asked the Plan to pre-approve additional mileage. You say that you need a knee replacement as soon as 
possible and you need to be seen by a specific provider. The Plan denied your request. The Plan says you are 
requesting an additional 80 miles for a total of 155 miles and your benefit only allows 75 miles. The Plan also 
says you have exceeded your benefit limit. 
 
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 up to 60 one-way trips and each one-way trip must not exceed 75 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 75 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 The file shows that a hereditary cancer panel was provided. We find that gene panel is not supported in the 
medical record. The medical records do not show that the enrollees treating physician ordered the testing for a 
specific medical problem. Medicare does not cover this testing for screening purposes. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. At this time, this procedure is not considered 
medically necessary. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastrorrhaphy services (43840) provided on October 26, 2021. 
 
You asked the Plan to pay for the gastrorrhaphy services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim is included in the global 
surgery package. 
 
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 43840 is Gastrorrhaphy, suture of perforated duodenal or 
gastric ulcer, wound, or injury. 
 
We looked at the file and Medicare rules. In this case, the enrollee underwent surgery coded as 44300 on 
October 24, 2022, which has a 90-day global surgery period. Code 43840 was not billed with a relevant 
modifier that indicates it would be paid separately from the global surgery payment for surgery coded 44300. 
Based on this information, we decided that Medicare rules for coverage of the gastrorrhaphy services have not 
been met. Therefore, we decided that the Plan does not have to pay for the gastrorrhaphy services (43840) 
provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
the provider was in network. You also say that you were advised the services were 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services you received are listed 
as covered, the frequency limits have been exceeded. The Plan coverage includes 1 comprehensive oral 
evaluation every 3 years and 1 panoramic x-ray every 5 years. The record shows that the Plan paid for a comprehensive oral evaluation and panoramic x-ray that you received on January 25, 2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray 
(D0330) provided on November 9, 2021.