Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services 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 physical 
therapy (PT) services provided on March 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand glucose monitor and test strips. 
 
You asked the Plan to pre-approve a non-preferred brand glucose monitor and test strips. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested home 
glucose meter and test strips are non-preferred brands. There is no documentation included in the medical 
records submitted as to a reason why the enrollee is unable to use one of the preferred diabetic glucose meters 
and test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract, and Medicare rules. The items at issue are a glucose monitor and 
diabetic test strips from a non-preferred brand. The services are available from the Plan's preferred brand. 
There is no documentation included in the medical records submitted as to a reason why the enrollee is unable 
to use one of the preferred brand diabetic glucose meters and test strips. Therefore, we decided that the Plan 
does not have to pre-approve a non-preferred brand glucose monitor and test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve connective tissue grafts on tooth #22 and 25 (D4273). 
 
You asked the Plan to pre-approve tissue grafts. You say that this service is medically necessary. The Plan 
denied your request. The Plan says connective tissue grafts (D4273) are not covered by your routine 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 
connective tissue grafts on tooth #22 and 25 (D4273).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (4) provided on March 28, 2022. 
 
You asked the Plan to pay for gingival irrigation - per quadrant (4). You say that you have been receiving 
periodontal maintenance since 2020, therefore you should not be charged. The Plan denied your request. The 
Plan says this service is not covered under your Plan. 
 
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 gingival irrigation - per 
quadrant (4) are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for gingival irrigation - per quadrant (4) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D4381, D4341, D4342, D9630, D4921, 
D0210 and D7140) on April 25, 2022, and April 29, 2022. 
 
You asked the Plan to pay for dental services (D4381, D4341, D4342, D9630, D4921, D0210 and D7140). You 
say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan 
says a full mouth complete series of x-rays (D0210) allows one procedure every five calendar years at 100% 
when services are performed by an in-network provider. The member already received a full mouth complete 
series of x-rays (D0210) on July 20, 2019. Also, extractions are allowed two procedure codes per calendar year 
at 100% when services are rendered by an in-network provider; thus, the third and fourth extractions (D7140) 
denied. Therefore, this benefit has been exhausted. According to the enrollee's EOC there is no coverage for 
dental services (D4381, D4341, D4342, and D4921).  
 
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 services (D4381, D4341, 
D4342, and D4921) are not among those covered under this benefit, while the coverage for services 
(D0210 and D7140) were exhausted. Therefore, we decided that the Plan does not have to pay for dental services 
(D4381, D4341, D4342, D9630, D4921, D0210 and D7140) on April 25, 2022, and April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on February 1, 2022. 
 
You asked the Plan to pay for the evaluation. You say that the exam is necessary to maintain basic dental 
health. The Plan denied your request. The Plan says the service provided is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 20610 and 23066 billed for date of service 
March 21, 2022. 
 
You asked the Plan to pay for procedure code 20610 and 23066. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 20610 and 23066 is bundled into payment for code 
29823. 
 
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 codes 
20610 and 23066 are column II codes to column I code 29823. 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 20610 and 23066 billed for 
date of service March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the claim meets Medicare guidelines and 
should be reprocessed. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on March 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aveloplasty (D7321). 
 
You asked the Plan to pre-approve aveloplasty. You say that this service is medically necessary. The Plan 
denied your request. The Plan says aveloplasty (D7321) is not covered by 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 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 
aveloplasty (D7321).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray (73502) provided on November 15, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this claim should be reconsidered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hip x-ray (73502) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewing 
radiographic images (D0274), and teeth cleaning (D1110) provided on April 11, 2022, by an out-of-network 
provider. 
 
You asked the Plan to pay more for the dental services. You say that the provider is a participating provider. 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 a periodic oral evaluation (D0120), bitewing 
radiographic images (D0274), and teeth cleaning (D1110) provided on April 11, 2022, by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 19, 2021. 
 
You asked the Plan to pay for procedure code 99070. You say that medical records are attached for further 
processing of the claim. The Plan denied your request. The Plan says procedure code 99070 is considered 
bundled and 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 procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), urinalysis (81000), and measurement 
of post-voided urine (51794) provided on February 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered 
to the enrollee. The Plan also says that the services were not urgent or emergent in nature. 
 
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 in this case is not a network provider with the Plan. 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 office visit (99204), urinalysis (81000), and measurement of 
post-voided urine (51794) provided on February 7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services 
provided on May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation with medical services. You say that the 
providers rely on facility staff to verify eligibility and obtain authorization from the patients insurance 
company. 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 psychiatric diagnostic evaluation with medical 
services provided on May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that this evaluation should be covered since it was 
with a new dentist. 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 October 20, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went to another provider listed in the 
directory and was informed you needed a cleaning. 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 Plan's 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 20, 2021. 
Therefore, we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on 
November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin base maxillary partial denture (D5211) on April 21, 2022. 
 
You asked the Plan to pay for a resin base maxillary partial denture (D5211). You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a resin 
base maxillary partial denture (D5211) on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (5211). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested 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 15, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (5211).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for MRI provided on April 28, 2022.

You asked the Plan to waive the copayments for MRI's. You say that you thought this was covered. The Plan denied your request. The Plan says the copayments applied are 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 $180 of the cost for each Medicare-covered special imaging procedure and special diagnostic test. 

You have been asked to pay $360 ($180 x 2) copayment for MRI's. MRI's falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for MRIs provided on April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease
(ESRD) provided on February 15, 2022.
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The
Plan says Medicare does not separately pay for ESRD-related laboratory testing.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an anterior resin-based composite of three surfaces provided 
on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed verbally or in writing 
prior to this procedure. You also say you were not informed that you would be financially responsible for this 
dental procedure because your benefits have been exhausted. 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 Plan's 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 10, 2022. Therefore, 
we decided that the Plan does not have to pay for an anterior resin-based composite of three surfaces provided 
on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided October 22, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that you feel the diagnosis code is incorrect. 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided October 22, 2021.