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

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950) and  resin-based composite - three surfaces, posterior (D2393) 
provided on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you cannot afford to pay the billed 
amount, you would like your insurance to pay the bill. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
  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. Enrollees maybe billed by the 
out-of-network provider for any charged amount greater than the payment made by the Plan. This benefit 
includes the requested crown - porcelain/ceramic (D2740) but is limited to one procedure per tooth every five 
plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You 
previously received covered crown - porcelain fused to high noble metal (D2750) January 30, 2020. Then you 
received crown - porcelain/ceramic (D2740) on December 13, 2022. Although these are two different services, 
they fall within the same category in your Evidence of Coverage and are subject to the same frequency 
limitations. Therefore, your benefit was exhausted on date of service January 30, 2022.  
 
You were billed $0 for core buildup, including any pins when required (D2950). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for resin-based composite - three surfaces, posterior (D2393). 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 pay more for crown - porcelain/ceramic (D2740), core 
buildup, including any pins when required (D2950) and  resin-based composite - three surfaces, posterior 
(D2393) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on December 12, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on December 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is a continuation of therapy. The Plan denied your 
request. The Plan says the drug will not be billed by the doctor's office. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hot or cold packs therapy (97010), 
electric stimulation therapy (97014), low level laser treatment (S8948), and the vertebral axial decompression, 
per session (S9090) provided on August 31, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the hot or cold packs therapy (97010), electric stimulation therapy 
(97014), low level laser treatment (S8948), and the vertebral axial decompression, per session (S9090) 
provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on November 18, 
2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the documentation does not 
include the time spent on this service. Based on this information, we decided that Medicare rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit coded 99214 provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260), debridement and osseous 
contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the 
exposed implant surfaces (D6102), bone graft for repair of peri-implant defect  does not include flap entry and 
closure (D6103), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and each 
subsequent 15 minute increment (D9243) provided on November 18, 2022. 
 
 
 You asked the Plan to pay for the dental services represented by codes D4260, D6102, D6103, D9239 and 
D9243. You say that these services should be covered as it is not a cosmetic procedure and you have 
cardiovascular disease. You also say that these services were necessary for you. The Plan denied your request. 
The Plan says these services are not covered under the benefit package. 
 
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 osseous 
surgery (D4260), debridement and osseous contouring of a peri-implant defect or defects surrounding a single 
implant and includes surface cleaning of the exposed implant surfaces (D6102), bone graft for repair of peri-
implant defect  does not include flap entry and closure (D6103), intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), and each subsequent 15 minute increment (D9243) provided on 
November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia services (D9222, D9223) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep 
sedation/general anesthesia services (D9222, D9223) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) provided on August 29, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your annual $1,000 dental benefit maximum 
allowance 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 May 18, 2022. Therefore, 
we decided that the Plan does not have to pay for a prefabricated abutment (D6056) provided on August 29, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xhance. 
 
You asked the Plan to pre-approve Xhance. You say that Xhance has worked well in the past. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xhance.  Benefits for Xhance may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visits. You say that you do not agree with the denial of these 
services. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the specialist visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64491 billed for date of service November 
29, 2022. 
 You asked the Plan to pay for procedure code 64491. You say that the medical records support the frequency of 
this code. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64491 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 64491 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 64491 billed for date of 
service November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on January 11, 2023. 
 
You asked the Plan to pay for an endosteal implant. You say that you are covered up to $2,000. The Plan 
denied your request. The Plan says this service has been correctly denied. 
 
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 an 
endosteal implant (D6010) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework 
with resin denture bases (D5214.) 
 
You asked the Plan to pre-approve the dental service. You say that your dentures were stolen. 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 19, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal 
framework with resin denture bases (D5214.)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an urgent care visit provided on September 28, 2022. 
 
You asked the Plan to pay for an urgent care visit. You say that you thought this clinic was covered, and feel it 
should be. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an urgent care visit 
provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral evaluation 
(D0120), and the bitewing x-rays-four radiographic images (D0274) provided on December 15, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 bitewing x-rays provided was exhausted on date of service January 25, 2022. 
Specifically, the Plan contract states that bitewing x-rays are covered once per year. You previously received 
this service on January 25, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit. Additionally, your benefit for the dental cleaning and periodic oral evaluation provided was exhausted 
on date of service June 14, 2022. Specifically, the Plan contract states that a dental cleaning and a periodic oral 
evaluation are covered twice per year. You previously received these services on January 25, 2022 and June 14, 
2022, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services.  
Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral 
evaluation (D0120), and the bitewing x-rays-four radiographic images (D0274) provided on December 15, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service November 
24, 2022. 
 You asked the Plan to pay for procedure code 93010. You say that the claim denied as a duplicate in error. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 31500. 
 
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 93010 
is a column II code to column I code 31500. 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 93010 billed for date of service November 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on September 20, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you are requesting reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is not part of the plan's network) will not be covered.

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 outpatient services provided on September 20, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric visit provided on November 21, 2022. 
 
You asked the Plan to pay for a psychiatric visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a psychiatric visit 
provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the compression 
stockings because you risk needing amputations if your lymphedema is not controlled. You also say that these 
items should be covered under your medical benefit since they are prescribed by your doctor to treat your 
diagnosed medical condition. The Plan denied your request. The Plan says you do not have a qualifying wound 
for coverage of compression stockings. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 14, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic services 
provided on February 14, 2022.