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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that you cannot afford to pay this bill. The Plan 
denied your request. The Plan says that the $1,000 annual maximum benefit 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 prophylaxis is listed as covered, the 
annual maximum benefit has been exceeded. After the annual maximum is exhausted, any remaining charges 
are your responsibility. 

 Date of Service Plan Paid 
1/20/2021 $72 
2/18/2021 $86 
2/22/2021 $133 
3/3/2021 $261 
3/10/2021 $58 
4/22/2021 $87 
5/25/2021 $308 
6/3/2021 $9 
TOTAL: $1,014 
 
Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to the waive the copayment for the telehealth specialist visit provided 
on January 28, 2022. 
 
You asked the Plan to the waive the telehealth specialist visit. You say you should not be charged another $35 
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $35 
copayment for consultation by a Specialty Physician. 
 
You have been asked to pay a $35 copayment for the telehealth specialist visit. Telehealth specialist visits falls 
within the telehealth services with a Specialty Physician 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 waive 
the telehealth specialist visit provided on January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MVASI, Doxorubicin and Carboplatin for the enrollee. 
 
You asked the Plan to pre-approve MVASI, Doxorubicin and Carboplatin. You say that these drugs are 
medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of 
for MVASI (bevacizumab), Doxorubicin, and Carboplatin in the setting of high-grade serous carcinoma of the 
endometrium have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 MVASI, Doxorubicin and Carboplatin. 
Our reviewer says that MVASI, Doxorubicin and Carboplatin are not medically reasonable and necessary. 
MVASI, Doxorubicin and Carboplatin are not FDA-approved for the enrollees diagnosis. The use of these 
drugs is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of MVASI, Doxorubicin and Carboplatin. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MVASI, Doxorubicin and Carboplatin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve MVASI, Doxorubicin and Carboplatin for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2-L5 decompression and fusion for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services are not medically necessary for the enrollee. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve L2-L5 decompression and fusion for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for an office visit on August 12, 2021. 
 
You asked the Plan to waive the $45 copayment for an office visit on August 12, 2021. You say that the 
provider was insistent you come back. You also say you feel this office visit was unnecessary and you shouldn't 
have to pay a $45 copayment. The Plan denied your request. The Plan says you are responsible for a $45 
copayment. Please note we are aware you are appealing additional dates of service. Those are being handled 
separately under appeal number 1-11146857956. A decision is still pending. You will be notified when it is 
decided. 
 
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 $45 
copayment for physician/practitioner services, including doctor's office visits.  You have been asked to pay a $45 copayment for an office visit. Office visits fall within the 
physician/practitioner services, including doctor's office visits 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 waive the $45 copayment for an office visit on August 12, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation (99254) provided on December 1, 
2021. 
 
You asked the Plan to pay for the inpatient consultation. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to 
pay for the inpatient consultation (99254) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), and panoramic x-ray (D0330) provided on September 30, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and panoramic x-ray. You 
say that you owe nothing because the practice insisted that these services would be covered by your insurance. 
The Plan denied your request. The Plan says the frequency limits for these services have 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, comprehensive oral evaluation 
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years, and bitewing 
x-rays are limited to one procedure per plan year. The record shows that you received a comprehensive oral 
evaluation (D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330) on January 20, 2021 and your 
comprehensive oral evaluation (D0150), bitewing x-rays, and panoramic x-ray (D0330) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) for tooth # 7 
provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received several treatments of 
chemotherapy. You also say that the crown has deteriorated as a result of the side effects. The Plan denied your 
request. The Plan says a crown and core build up are covered once per tooth per every 5 plan years. The Plan 
also says that the frequency limits have been exceeded. 
 
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 crown and core build up are listed 
as covered, the frequency limits of once per tooth every 5 plan years has been exceeded. The record shows that 
the Plan paid for a crown and core build up for tooth # 7 that you received on November 11, 2019. Therefore, 
we decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) for tooth # 7 
provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on January 31, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that it was necessary for you to receive this 
service, or there would be no bottom plate at all, and you would have to go without bottom teeth. You also say 
that you would like the Plan to pay the full amount, or at least 50% of the cost. 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, 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 bone replacement graft for ridge preservation 
(D7953) provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on September 23, 
2021, to October 2, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that due to the hospital room 
and the conditions of it you were told you would not have to pay the $700. The Plan denied your request. The 
Plan says the copay applied is correct. 
 
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 $100 
copayment each day for days 1 through 7 for Inpatient Hospital Care.  
 
 You have been asked to pay $700 copayment for days 1 through 7 for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital Care 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 waive the copayment 
for inpatient hospital stay on September 23, 2021, to October 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like to appeal the denied claim. 
The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 the laboratory services provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on August 12, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code 
remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. 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 validity testing provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided from July 4, 2021, to July 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
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 99497 is a column II code to column I code 99291 with a modifier 
indicator of 0. The column II code is therefore not payable. We also find that CPT code 99291, billed for 
services provided on July 5, 2021, is not supported in the medical records. 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 
physician services provided from July 4, 2021, to July 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and application of autologous blood 
concentrate product (D7921) and sinus augmentation with bone or bone substitutes (D7951) provided on 
January 12, 2022. 
 
You asked the Plan to pay for the collection and application of autologous blood concentrate product and sinus 
augmentation. You say that these services are medical, not dental expenses. The Plan denied your request. The 
Plan says these services are not covered benefits. 
 
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 the collection and application of 
autologous blood concentrate product (D7921) and sinus augmentation with bone or bone substitutes (D7951) 
provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on August 13, 2021. 
 
You asked the Plan to pay for the consultation. You say that you were told the dentist accepted your plan which 
is why you went to see them. You also say that you were not advised that there would be any fee associated 
with this dental visit. The Plan denied your request. The Plan says this service is not covered under 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 the 
consultation (D9310) provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on October 15, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. 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 validity testing provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), prophylaxis 
(D1110), topical application of fluoride varnish (D1206), oral hygiene instructions (D1330), and application of 
caries arresting medicament (D1354) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim to be processed as in-
network, which you are entitled to. The Plan denied your request. The Plan says the services provided were not 
part of the Plan's dental covered procedures, they were routine dental services. The Plan also says that the 
enrollees plan does not include any supplemental dental coverage, nor did the member enroll in any optional, 
additional dental coverage. 
 
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 
the enrollees teeth or the structures directly supporting the enrollees 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 the periodic 
oral evaluation (D0120), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays 
(D0230 x2), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), 
oral hygiene instructions (D1330), and application of caries arresting medicament (D1354) provided on 
December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
December 7, 2021. 
 You asked the Plan to pay for the tooth extraction. You say that the opt out clause is arbitrary. The Plan denied 
your request. The Plan says this service is not covered because the provider has opted out of Medicare. 
 
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 the tooth 
extraction when you see any licensed dental provider who accepts Medicare patients in the United States and 
has not opted out of Original Medicare.  
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the tooth extraction have not been met. Therefore, we decided 
that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided December 7, 2021.  
 
Your complaint about feeling that the opt out clause is arbitrary 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic surgical system (S2900). 
 
You asked the Plan to pre-approve a robotic surgical system. You say that the services are necessary. The Plan 
denied your request. The Plan says code S2900 has a status indicator of I, which indicates that this service is 
not valid for Medicare purposes. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a robotic surgical system billed using code S2900 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a robotic surgical system (S2900).