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

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  first 15 minutes 
(D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that the sedation is medically 
necessary. 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 pre-approve deep 
sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 
15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the prophylaxis - adult (D1110), 
periodic oral evaluation - established patient (D0120), and intraoral - complete series of radiographic images 
(D0210) provided December 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the dental cleaning, periodic oral exam and complete 
series of x-rays. You say that you were unaware at the time of the services that the provider was OON. You do 
not understand why the full amount was not covered. The Plan denied your request. The Plan says these 
services have been covered according to your OON 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.  
The Plan rules say if you choose to see an Out-of-Network dentist, you might be billed for charges above what 
the Plan pays, even for services listed as $0 copayment. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the full allowed 
amount was covered by the Plan for each of the services at issue. You have been asked to pay the difference 
between the allowed amount and the total cost billed by the OON provider. Therefore, we decided that the Plan 
does not have to provide additional payment for the prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), and intraoral - complete series of radiographic images (D0210) provided 
December 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care provided on January 12, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen by distinct specialties. 
The Plan denied your request. The Plan says that the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99232 is supported in the medical record. The records show that the code at issue was 
provided by a separate physician than who performed the enrollees procedure. The records do not include a 
transfer of care. Based on this information, we decided that Medicare rules for coverage of the services have 
been met. Therefore, we decided that the Plan has to pay for the subsequent hospital care provided on January 
12, 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 the limited oral evaluation - problem focused (D0140) 
provided December 23, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this emergency exam was necessary. The 
Plan denied your request. The Plan says this service is not covered under you 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 the 
limited oral evaluation - problem focused (D0140) provided December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and fluoride treatment (D1206) 
provided by a participating provider on December 7, 2021. 
 
You asked the Plan to pay for intraoral imaging and fluoride treatment. You say that you were never told how 
much your out-of-pocket would cost. You say that you were not given the option to decline the services. The 
Plan denied your request. The Plan says D0210 has already been exhausted. The Plan says that D1206 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. The Plan covers intraoral 
imaging once every three years. The Plan does not cover fluoride treatment. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 was previously provided 
on May 3, 2021. Based on this information, we decided that the Plan's rules for coverage of intraoral imaging 
have already been met, and fluoride treatment is not a covered benefit. Therefore, we decided that the Plan does 
not have to pay for intraoral imaging (D0210), and fluoride treatment (D1206) provided by a participating 
provider on December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) provided 
on April 18, 2021, by a non-participating provider. 
 
You asked the Plan to pay for ambulance oxygen and oxygen supplies. You say that you disagree with the 
denial of charges. The Plan denied your request. The Plan says the cost of oxygen and its administration in 
connection with and as part of the ambulance service is covered. Under the ambulance FS, oxygen and other 
items and services provided as part of the transport are included in the FS base payment rate and are not 
separately payable. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance oxygen and oxygen supplies have not been met. Specifically, oxygen and other supplies 
are included in the base payment rate of the transport. Therefore, we decided that the Plan does not have to pay 
for ambulance oxygen and oxygen supplies (A0422) provided on April 18, 2021, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, four or more teeth per 
quadrant (D4341) provided on October 13, 2021. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you disagree with the denial 
and would like the plan to reconsider. The Plan denied your request. The Plan says the requested service is 
excluded from coverage and not a benefit. 
 
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 
periodontal scaling and root planing, four or more teeth per quadrant (D4341) provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 27691 is 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 27691 is transfer or transplant of single tendon (with 
muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor 
digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot).  
We find that CPT code 27691 is not supported in the medical record. Specifically, there is no documentation of 
a deep transfer or transplant of a single tendon. 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 pay for the 
surgical services rendered on September 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 4, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
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 laboratory services provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 88341 and 88342 provided on 
October 11, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed 
with these codes. 
 
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 
88341 and 88342 are both column II codes to column I code 88360. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical services coded 88341 and 88342 
provided on October 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 93320 and 93325 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 93320  is Doppler echocardiography, pulsed wave and/or 
continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); 
complete. The definition of code 93325 is Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography). 
 
We find that CPT codes 93320 and 93325 are not supported in the medical record. Specifically, these are add-
on codes that were not billed with a required primary procedure code. 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 pay for the testing services rendered on March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
November 10, 2021. We also decided that the Plan does not have to waive the copayment for a specialist office 
visit provided on November 19, 2021. 
 You asked the Plan to waive the copayments for the ECG and specialist office visit. You say that you feel the 
provider applied your copayment to older bills. 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 $20 
copayment for non-radiological diagnostic services, including ECG's. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for services obtained from a 
specialist. 
 
You have been asked to pay $15.61 for the ECG, which is less than the $20 copayment. The ECG falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been 
asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 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 copayments for an electrocardiogram (ECG) provided on November 10, 2021. We also decided 
that the Plan does not have to waive the copayment for a specialist office visit provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 
29, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 99153 may not be paid 
if furnished to a hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is not supported in the record. Specifically, the record indicates that the enrollee 
was in an outpatient hospital setting on the billed date of service. CPT code 99153 has a Professional/Technical 
Component Indicator of 3 meaning that it is the Technical Component of a diagnostic test. Payment for this 
service is included in the payment to the facility and is the responsibility of the facility to any vendor. Based on 
this information, we decided that Medicare rules for coverage of the moderate sedation services have not been 
met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam - three surfaces, primary or permanent (D2160) 
provided December 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the amalgam. You say that the provider is in-network. The Plan denied your 
request. The Plan says these services are not covered because the provider is OON. 
 
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 Plan covers the amalgam 
when provided in-network. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the provider is OON 
as of December 20, 2021. Based on this information, we decided that the Plan's rules for coverage of the amalgam have not been met. Therefore, we decided that the Plan does not have to pay for the amalgam - three 
surfaces, primary or permanent (D2160) provided December 30, 2021, by an out-of-network (OON) provider.  
 
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held 
responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form, 
indicating that you are a non-contract provider. 
 
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through 
the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will 
need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2751), prefabricated post and core in addition to 
crown (D2954), and endodontic therapy (D3310) provided from December 2, 2021, to December 21, 2021. 
 
You asked the Plan to pay for the crown, prefabricated post and core, and endodontic therapy. You say that you 
would like these services to be covered. The Plan denied your request. The Plan says you have exceeded your 
maximum benefit, and maxed out the $1,000 allowable benefit for the 2021 plan year. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on November 19, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the crown (D2751), prefabricated post and core in addition to 
crown (D2954), and endodontic therapy (D3310) provided from December 2, 2021, to December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 24, 2021. 
 
You asked the Plan to pay for dental services. You say that you were not aware that this doctor was out-of-
network. The Plan denied your request. The Plan says services provided by an out-of-network provider are not 
covered 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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an out-of-network provider on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (CPT code 
V2788) provided on November 3, 2021. 
 
You asked the Plan to pay for the service. You say that you had the same procedure done the prior year and it 
was covered. You state it was the same doctor at the same hospital as before. The Plan denied your request. 
The Plan says the plan reviewed your past claim and found that on March 4, 2020, you received vision services 
with procedure code V2788, which denied payment in the amount of $819.50. The Plan states this procedure 
code was non-covered in March of 2020, as it is for date of service, November 03, 2021. 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Presbyopia correcting function of 
intraocular lens (CPT code V2788) is not covered by Medicare or your health plan. Therefore, we decided that 
the Plan does not have to pay for presbyopia correcting function of intraocular lens (CPT code V2788) 
provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation provided by an out-of-network 
provider on December 20, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation. You say that you do not feel like you should be held 
liable for this. The Plan denied your request. The Plan says the benefit limit for a periodic oral evaluation 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. The Plan covers a periodic 
oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a periodic oral evaluation was 
previously provided on March 17, 2021, and June 21, 2021. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation provided by an out-of-network provider on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that you had a partial root canal 
done to relieve your pain but was unable to complete the root canal due to excessive infection and fractured 
tooth. You also say that you had to have the tooth extracted. The Plan denied your request. The Plan says this 
service 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 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 the 
incomplete endodontic therapy (D3332) provided on December 20, 2021.