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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 25, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 limited 
oral evaluation (D0140) provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, first level (22869) and second level (22870).

You asked the Plan to pre-approve Vertiflex procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 Vertiflex procedure. Our reviewer says that the requested Vertiflex procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental. The reviewer found that there is a lack of research for the Vertiflex procedure. Therefore, the reviewer found the requested Vertiflex procedure is 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, first level (22869) and second level (22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you need this item as a result of your 
medical condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the 
Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited (problem-focused) oral evaluation (D0140), an 
intraoral x-ray (D0220), and a porcelain/ceramic crown (D2740) provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were told you would still receive 
reimbursement for the crown despite the provider's out-of-network status. 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 a limited (problem-focused) oral evaluation (D0140), an intraoral x-ray (D0220), and a 
porcelain/ceramic crown (D2740) provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 18, 2021, to 
August 29, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records and the clinical presentation of the enrollee support the original coding of this claim and 
removal of the secondary diagnosis code is unjustifiable. You say that the claim should be reinstated at the 
originally billed DRG. The Plan denied your request. The Plan says secondary diagnosis code G92 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G92, defined as toxic 
encephalopathy. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support secondary 
diagnosis code G92 and originally billed DRG 682. Our physician reviewer found there was no clinical or 
laboratory evidence of metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from August 18, 2021, to August 29, 2021, at the DRG originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code billed for services provided on June 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the charges were appropriate for the level of 
services provided. The Plan denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 96374 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); intravenous push, single or initial substance/drug. We find that CPT code 96374 
has a PC/TC indicator of 5. The claim billed a place of service as 23, a hospital emergency room. Payment may 
not be made by carriers for these services when they are provided to patients in a hospital outpatient 
department. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code billed for services 
provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement glasses. 
 
You asked the Plan to pre-approve replacement glasses. You say that your glasses were lost with your luggage 
during traveling. You also say that you cannot see without the glasses. The Plan denied your request. The Plan 
says replacements due to loss, damage, style or stolen (glasses or contact lenses) are not covered. 
 
  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan says that replacements due to loss, damage, style or stolen (glasses or contact lenses) are not 
covered, unless otherwise stated in plan documents. 
 
We looked at the file and the Plan's rules. The rules say that they do not replace glasses or contact lenses due to 
being lost or stolen. Based on this information, we decided that the Plan's rules for coverage of replacement 
glasses have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement 
glasses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391 x3) 
provided on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you pay a premium for this insurance and you 
need to have teeth so you can eat. You say you are asking the Plan to pay the bills the provider has sent in. 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 July 26, 2022. Therefore, 
we decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391 x3) 
provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tie down loop. 
 
You asked the Plan to pre-approve the tie down loop. You say that this is necessary for the operation of the 
ordered power wheelchair. The Plan denied your request. The Plan says equipment to be used outside of the 
home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the tie down loop.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for continuous positive airway pressure 
(CPAP) device (A9270). 
 
You asked the Plan to pre-approve a battery backup for CPAP. You say that the member needs this item. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a battery backup for CPAP have not been met. Specifically, this is not a Medicare covered item. 
Therefore, we decided that the Plan does not have to pre-approve a battery backup for continuous positive 
airway pressure (CPAP) device (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 25, 2022, to June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 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 dental 
services on May 25, 2022, to June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia (D9222 and D9223), therapeutic parental 
drugs (D9612), a surgical extraction (D7210), and alveoplasty (D7310), provided by a participating provider. 
 
You asked the Plan to pre-approve anesthesia, therapeutic parental drugs, a surgical extraction, and alveoplasty. 
You say that you need your teeth removed because they are infected. The Plan denied your request. The Plan 
says the requested services 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 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 
anesthesia (D9222 and D9223), therapeutic parental drugs (D9612), a surgical extraction (D7210), and 
alveoplasty (D7310), provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that this is necessary for your condition. The Plan denied 
your request. The Plan says this item is not covered by Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intra-oral x-rays and an extraction (D0220, D0230, D7140 ) 
provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  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 intra-oral x-rays and an 
extraction (D0220, D0230, D7140 ) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2950, D2740) provided 
on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 29, 2019. 
Therefore, we decided that the Plan does not have to pay for a crown and core buildup services (D2950, 
D2740) provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the visits for substance abuse treatments and drug tests 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the visits for substance abuse treatments and drug tests. You say that you 
would like the request for services to be approved. The Plan denied your request. The Plan says the requesting 
provider is an OON provider and there are multiple in-network providers that the enrollee can receive the 
requested services from. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the visits for substance abuse treatments and drug tests to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
cardiologist. 
 
You asked the Plan to pre-approve the physician services. You say that you would like to continue to see this 
provider. The Plan denied your request. The Plan says the requested services are available in-network. The Plan 
also says the requested services are not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve office visits to be provided by an out-of-network (OON) cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a set of complete upper and lower dentures (D5110, D5120) 
provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were a medical emergency. The 
Plan denied your request. The Plan says the claim was processed correctly. The services at issue are not 
covered under your dental benefit package. The Plan also says that there is no clinical evidence to support the 
medical necessity of these services. 
 
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 set of 
complete upper and lower dentures (D5110, D5120) provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve other accessories, an ultra-long facial pad (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested accessory does not meet the definition of DME as it is not 
primarily used for medical purposes. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve other accessories, an ultra-long facial pad (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit provided on February 08, 
2022, to February 15, 2022. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you received poor services so you 
shouldnt have to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 10% 
coinsurance for Doctor and other health care provider services. 
 
You have been asked to pay 10% coinsurance for office visit. This item/service falls within the Doctor and 
other health care provider 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 coinsurance for 
office visit provided on February 08, 2022, to February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the comprehensive periodontal 
evaluation - new or established patient (D0180) and 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided June 23, 2022. 
 
You asked the Plan to provide additional payment for the comprehensive periodontal exam and 2D oral/facial 
photographs. You say that you were not informed about copayments prior to the dental work being performed. 
The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
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 comprehensive periodontal exam with a $33 copayment and 2D oral/facial photographs with a $62 copayment. 
 
We looked at the file and Medicare rules. You have been asked to pay a $33 copayment for the comprehensive 
periodontal exam and a $62 copayment for the 2D oral/facial photographs. This means 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 provide 
additional payment for the comprehensive periodontal evaluation - new or established patient (D0180) and 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided June 23, 2022.  
 
Your complaint about  not feeling adequately informed about copayments prior to the services being performed 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.