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

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on November 1, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the simple extraction. You say that you did not know this doctor was not part of 
Medicare. The Plan denied your request. The Plan says you received this service from a provider who chose 
not to receive Medicare funds. The Plan also says that they contacted the treating provider's office and were 
advised that the provider had opted out of Medicare and the practice informed their patients verbally. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the simple extraction (D7140) provided on November 1, 2021 by a Medicare opt 
out provider.
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 additions of a tooth to an existing partial denture (D5650 x2) 
provided on July 8, 2021, and August 3, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
tooth additions. You say that patients should be able to try to keep their teeth as long as possible, and you 
would like to appeal these services. The Plan denied your request. The Plan says your benefits for these 
services have been satisfied and the frequency limitations have been exceeded. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periodic oral exam (D0120) and 
problem focused limited oral evaluation (D0140) share a frequency limitation of two procedure codes per 
calendar year. The record shows that you received a problem focused limited oral evaluation (D0140) on 
February 4, 2021, and a periodic oral exam (D0120) on April 20, 2021 and your periodic oral exam (D0120) 
and problem focused limited oral evaluation (D0140) benefits have been exhausted. The Plan contract also says 
that intraoral x-rays and denture adjustments are each limited to one procedure code per calendar year. The 
record shows that you received one first intraoral periapical x-ray (D0220) on July 8, 2021, and you received 
an addition of a clasp to an existing partial denture (D5660) on August 3, 2021, and your intraoral x-rays and 
denture adjustments benefits have been exhausted. 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 additions 
of a tooth to an existing partial denture (D5650 x2) provided on July 8, 2021, and August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), prefabricated abutment (D6056), abutment supported porcelain fused to metal crown 
(D6059), two implant supported retainers (D6075 x2), and operating room (D9500). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutment, abutment supported 
porcelain fused to metal crown, implant supported retainers, and operating room. You say that you really need 
the implants because you and an injury and cannot eat well. The Plan denied your request. The Plan says these 
services are not covered under your benefit 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 pre-approve two 
surgical placements of implant bodies: endosteal implants (D6010 x2), prefabricated abutment (D6056), 
abutment supported porcelain fused to metal crown (D6059), two implant supported retainers (D6075 x2), and 
operating room (D9500).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy and the records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. You have been approved for ample therapy and time to 
be thoroughly instructed in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits (97110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve the requested items. You say that the enrollee is expected to engage in 
unlimited community ambulation. The Plan denied your request. The Plan says the knee is not reasonable and 
necessary per Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested items. Our physician 
reviewer found that the requested items exceed the patient's medical need. There is no physician documentation 
indicating why the enrollees function cannot be met effectively with a mechanical K3 knee. Therefore, the 
requested items are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayments for prescription drugs and the 
specialist office visits provided on May 24, 2021, July 26, 2021, and August 23, 2021. 
 
You asked the Plan to waive the coinsurance and copayments for the prescription drugs and specialist office 
visits. You say that you would like the cost shares waived because you cannot afford it. The Plan denied your 
request. The Plan says the proper coinsurance and copayments were applied. 
  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 20% 
coinsurance for Medicare-covered Part B drugs. For each date the total coinsurance charged was $3.24 ($16.18 
total amount charged x 20% coinsurance). The total amount of the coinsurance for the 3 dates was $9.72 ($3.24 
coinsurance amount x 3 dates). 
 
Your contract with the Plan also clearly says that you must pay a $5 copayment for each Medicare-covered 
specialist visit. The total amount of copayments for the 3 dates was $15 ($5 copayment x 3 visits). 
 
You have been asked to pay a $9.72 coinsurance for the prescription drugs and a $15 copayment for the 
specialist office visits. The prescription drugs falls within the Medicare Part B prescription drugs benefit 
category. The specialist office visits falls within the Physician/Practitioner services, including doctors 
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 coinsurance and copayments for 
prescription drugs and the specialist office visits provided on May 24, 2021, July 26, 2021, and August 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 24, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were referred to this provider. You say they 
determined that surgery was not necessary. You say that you were not aware that you are allowed only 1 
comprehensive review every 3 years. You also say that this will cause you undue hardship as the expense due 
to your limited budget. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is 
covered every 3 years. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 comprehensive oral evaluation is 
covered every 3 years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on September 4, 2021. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-rays 
(D0220 x 2) provided on February 16, 2021 by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that the dental office assured you that they were in 
network. You also say that you feel you are not responsible for this bill since you were misinformed. The Plan 
denied your request. The Plan says dental services received out of network are not covered. 
 
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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-rays (D0220 x 2) provided on February 16, 2021 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), and filling (D2393) provided from March 11, 2021, to April 14, 2021 by a provider that has 
opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you were misinformed regarding your dental 
benefit. You say that you were advised the only exceptions were cosmetic services. You also say you were 
advised that the dentist does not have to be Medicare participating. The Plan denied your request. The Plan 
says dental services performed by a provider that has opted out of Medicare are not covered. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), 
and filling (D2393) provided from March 11, 2021, to April 14, 2021 by a provider that has opted out of 
Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on May 6, 2021. 
 
You asked the Plan to pay for the core buildup. You say that you were advised by the provider's office that both 
crowns were approved by the Plan, and you could get them done. The Plan denied your request. The Plan says 
this service is not covered by your health plan or Medicare. The Plan also says that you signed a treatment plan 
on April 27, 2021 that shows $0 coverage for the core buildup and acknowledging that you would be 
responsible for the charge for this service. 
 
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 core 
buildup, including any pins when required (D2950) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on August 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that no authorization required for an office visit. The Plan denied your request. The Plan says the rendering provider is a non-participating provider and there is no referring provider involved in these services. The Plan also says that they did not authorize any services for this 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 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 an office visit (99204) provided on August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81227, 81479, 81240, 81241, 81291, 
81479, and 81355) provided on June 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81227, 81479, 81240, 81241, 81291, 81479, and 81355) provided on June 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine dental services provided on October 13, 2020. 
 
You asked the Plan to pay for routine dental services. You say that the Plan should reevaluate its denial. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover dental services. 
 
In this case, the case record documents that the Plan offers an optional dental benefit that exceeds Medicare 
coverage. However, the Plan indicates that you were not participating in the optional dental benefit on the date 
of service at issue. The services you are asking the Plan to pay for involve the care, treatment, filling, removal 
or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for routine 
dental services provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on May 11, 2021. 
 
You asked the Plan to pay for the crown. You say that this was a normal dental procedure which should be 
covered. 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 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 crown 
(D2740) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
March 16, 2021, to April 26, 2021. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that your husband went to his 
primary care physician (PCP) on March 16, 2021, and April 26, 2021. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. The Plan also says that the provider did not 
become your husbands primary care physician (PCP) until July 1, 2021. 
 
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 $40 
copayment for a specialist visit.   
The records shows that the provider became your husbands PCP effective July 1, 2021. You have been asked 
to pay a $40 copayment for each specialist office visit on March 16, 2021, and April 26, 2021. A specialist 
office visits falls within the Physician/Practitioner Services, Including Doctors 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 specialist office visits provided from March 16, 2021, to 
April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and ankle system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic additions are covered when reasonable 
and medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that the 
enrollee had a left above knee amputation from vascular complications. He is approved for an above knee 
prosthesis. The requested microprocessor knee and ankle system exceeds his medical needs, as the physician 
documentation does not support that he is unable to use a mechanical knee and ankle/foot. The services are 
therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a microprocessor knee and ankle system.