Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot find an in-network provider. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. The Plan have found multiple in-network 
providers within a 20-mile radius of your zip code. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the requested items or services are not covered under this benefit when received from an 
out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visit provided on January 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for specialist office visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 specialist office visit provided on January 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory virus panel with 12-25 pathogens billed with 
code 87633 for date of service January 28, 2022. 
 
You asked the Plan to pay for a respiratory virus panel with 12-25 pathogens. You say that  The Plan denied 
your request. The Plan says the test which remains in dispute is not covered by Medicare or under this contract. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels with more than 5 
respiratory pathogens performed in the Part B outpatient setting are considered not medically reasonable and 
necessary. 
 
We looked at the file and Medicare rules. The records show that the respiratory virus panel was performed in 
the Part B outpatient setting and involved more than 5 pathogens. Based on this information, we decided that 
Medicare rules for coverage of a respiratory virus panel with 12-25 pathogens have not been met. Therefore, 
we decided that the Plan does not have to pay for a respiratory virus panel with 12-25 pathogens billed with 
code 87633 for date of service January 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 May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility which indicates these tests are included in the dialysis rate. 
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 May 4, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 25, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that you have provided medical records to 
support payment for this procedure. The Plan denied your request. The Plan says payment for code 70450-26 is 
bundled into payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the periodic oral evaluation (D0120), bitewing x-rays-four 
radiographic images (D0274), and the dental cleaning (D1110) provided on March 24, 2022. 
 
You asked the Plan to pay more for the 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 that you are responsible for any charged 
amount above the Plans allowed amounts.  
 
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 providers charges and the Plans payment. However, 
in this case the dental services were rendered by an in-network provider. The Plans contract does not state that 
you will be responsible for the difference between the providers billed amount and the plans approved 
amount for these services. Therefore, we decided that the Plan has to pay more for the periodic oral evaluation 
(D0120), bitewing x-rays-four radiographic images (D0274), and the dental cleaning (D1110) provided on 
March 24, 2022.  
 
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 a resin-based composite (D2332) for tooth #24 provided by a 
participating provider on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why this is not covered. 
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 26, 2022, with 
tooth #25. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2332) for 
tooth #24 provided by a participating provider on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) and periodontal maintenance 
(D4910) provided by a participating provider on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered. 
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 D0220 was exhausted on date of service June 16, 2022, with D0230. D4910 is not a 
covered dental benefit. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220) 
and periodontal maintenance (D4910) provided by a participating provider on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on June 6, 
2022. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you needed to get a new denture 
because your last one was accidentally broken and could not be repaired. 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 
maxillary partial denture (D5211) provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that acupuncture has helped you to be able to do daily 
tasks without more medication or surgery. The Plan denied your request. The Plan says acupuncture is only 
covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Medicare covers acupuncture for patients with chronic low back pain (CLBP). The file shows that the requested acupuncture is for pain in your legs, knees, 
back neck and shoulders. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided on November 12, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for radiology services (70450) provided on November 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 to 8 hours of in-home support. 
 
You asked the Plan to pre-approve the additional hours of in-home support. You say that you need additional 
hours for medical purposes because you are handicapped. The Plan denied your request. The Plan says the 
request for more than 30 hours of the in-home support program is not covered. 
 
Medicare generally does not cover custodial care services. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at the file and Medicare rules. Though the Plan offers an in-home support benefit in excess of 
Medicare coverage, certain limitations apply. The record shows that as of September 21, 2022, you had 90 
minutes remaining under your benefit program. Once you have depleted the remaining 90 minutes, your in-
home support benefit will be exhausted, and additional time cannot be approved. Therefore, we decided that the 
Plan does not have to pre-approve an additional 6 to 8 hours of in-home support.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) and topical application of fluoride 
varnish (D1206) provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan benefits indicate that you are allowed 
at least two dental cleanings and fluoride treatments. You also say that there is no indication in the benefits that 
these services are limited monetarily. The Plan denied your request. The Plan says your annual maximum 
benefit for the requested services has already been exhausted. The Plan also says it was confirmed that you 
were not enrolled in the supplemental dental rider which offers additional 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, certain limitations apply. The record 
shows your annual maximum benefit for the requested services was exhausted on date of service February 18, 
2022. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and topical 
application of fluoride varnish (D1206) provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and two crowns (D2740 x2) provided on May 31, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
crowns. You say that your tooth cracked in half and the doctor felt it could be repaired instead of pulled. You 
also say that you would like to know why this portion of the procedure would not be covered since it was due 
to an accident. The Plan denied your request. The Plan says these services are not covered benefits 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 the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and two crowns 
(D2740 x2) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy on tooth #2 (D3330), core build-up 
on tooth #2 and #7 (D2950), and endodontic therapy, anterior, on tooth #7 (D3310) provided on December 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied claim. 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 December 6, 2021. The 
record shows the Plan paid $600 towards the services. Therefore, we decided that the Plan does not have to pay 
for the endodontic therapy on tooth #2 (D3330), core build-up on tooth #2 and #7 (D2950), and endodontic 
therapy, anterior, on tooth #7 (D3310) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on March 14, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the dental provider 
told you this service was covered by the Plan. The Plan denied your request. The Plan says your benefit for the 
requested 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 service was exhausted on date of service January 4, 2022. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on 
March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104) 
provided on May 16, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy. 
 
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 service provided is not among 
those covered under this benefit.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the bone graft at time of implant placement 
(D6104) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the treating dentist accepted 
your insurance. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
April 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided May 17, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you were feeling better and thought it 
would be less expensive to not be transported. The Plan denied your request. The Plan says this service is not 
covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on May 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), unspecified adjunctive procedure (D9999), and simple extraction (D7140) 
provided on February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you could not find an in-network provider in 
your area. You also say that you would like to be reimbursed for the extractions. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), 
unspecified adjunctive procedure (D9999), and simple extraction (D7140) provided on February 8, 2022, by an 
out-of-network (OON) provider.