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

 
We decided that the Plan does not have to pay for the maxillary partial denture (code D5213) provided on 
January 31, 2022 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the partial denture. You say that this is a covered service, so the Plan needs to 
pay this. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
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 when provided out-of-network.  
 
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 the maxillary partial denture (code D5213) 
provided on January 31, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin repair of partial maxillary (upper) denture base (D5612) 
provided on November 30, 2021. 
 
You asked the Plan to pay for the denture repair services. You say that you are a senior wearing dentures and 
occasionally dentures need realignment or adjustments to make them adequate for chewing. You also say that 
the Plan provides services for seniors and should cover areas relevant to senior health, such as dentures.  
The Plan denied your request. The Plan says the denture repair services you requested are not a covered benefit 
under your dental 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 pay for resin 
repair of partial maxillary (upper) denture base (D5612) provided on November 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77065, G0279) provided April 8, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 77065 & G0279 is not supported in the medical record. Specifically, these services 
were paid on previous claims for the same date of service. Records do not support additional instances of these 
services. Based on this information, we decided that Medicare rules for coverage of the radiology services have 
not been met. Therefore, we decided that the Plan does not have to pay for radiology services (77065, G0279) 
provided April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided by an out-of-network 
provider on December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 
services 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 the drug testing services provided by an out-of-network provider 
on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being 
provided in the current acute care setting which is already approved. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
was admitted with sepsis from acute cholecystitis. The record indicates that the enrollee requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on November 27, 2020. 
 
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 that code 99285 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that billed code 99285 is not separately payable due to 
incidental/mutually exclusive National Correct Coding Initiative (NCCI) edits; however, the file shows that the 
code was not billed with another code for the date of service at issue. The Plan has not provided any 
documentation or Medicare rules to support that the services are not payable as billed. Therefore, we decided 
that the Plan has to pay for the emergency room (ER) services rendered on November 27, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for spinal stenosis. Your medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950) and endodontic therapy (D3310) 
provided on February 16, 2022. 
 
You asked the Plan to pay for core build up and endodontic therapy. You say that the root canal was medical 
necessary. The Plan denied your request. The Plan says that core build up (D2950) and endodontic therapy 
(D3310) are not covered by your supplemental 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 core build 
up (D2950) and endodontic therapy (D3310) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (code 
D0220) provided on March 1, 2022. 
 
You asked the Plan to pay for the intraoral x-ray (code D0220). You say that you were advised to submit an 
appeal. The Plan denied your request. The Plan says only one procedure code for intraoral x-rays is covered 
every calendar year. You received two procedure codes for intraoral x-rays (D0220 and D0230) on March 1, 
2022. Code D0230 was covered by the plan and code D0220 was denied coverage. 
 
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 only one 
procedure code of an intraoral x-ray when the services are medically necessary and reasonable per calendar 
year. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic 
image (code D0220) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0210) provided on March 21, 2022. 
 
You asked the Plan to pay for the intraoral x-ray. 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 coverage. 
 
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 
intraoral x-ray (D0210) provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (procedure code 97012) 
services you received from a chiropractor from January 5, 2022, to February 2, 2022. 
 
You asked the Plan to pay for the mechanical traction therapy. You say that you believe these are covered 
services and you verified this with customer service. The Plan denied your request. The Plan says because this 
particular code does not represent manual manipulation of the spine, it is a non-covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy (procedure code 97012) services you received 
from a chiropractor from January 5, 2022, to February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 23, 2020. We also decided the Plan does not have to pay for an extraction (D7210) and a preventive 
procedure (D1999) provided on December 16, 2020. 
 
You asked the Plan to pay for an evaluation, extraction, and preventive procedure. You say that you disagree 
with the denial for dental services. The Plan denied your request. The Plan says these services are covered by 
the Plan's dental benefits; however, the annual limit for preventive and comprehensive dental services been 
exhausted. 
 
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 there is an annual 
allowance of $255 for out-of-network non-Medicare covered dental services.  The contract also says you are responsible for any amount above the dental coverage limit. 
 
The record shows the Plan paid the $255 annual allowance for non-Medicare preventive and comprehensive 
dental services. According to the EOC, you are responsible for any amount above the dental coverage limit. 
 
Date of Service Code Allowed Amount Amount Over Annual 
Limit 
September 23, 2020 D0150 $129.20 $47.10 
December 16, 2020 D7210 $347 $347 
December 16, 2020 D1999 $15 $15 
Total   $409.10 
 
You have been asked to pay a total of $409.10 for the amount above the dental coverage limit. An evaluation, 
extraction, and preventive procedure falls within the Dental 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 pay for a comprehensive oral evaluation (D0150) provided on September 23, 2020. We also 
decided the Plan does not have to pay for an extraction (D7210) and a preventive procedure (D1999) provided 
on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on March 1, 2022. 
 
You asked the Plan to pay for the core buildup. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental coverage. 
 
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 core 
buildup (D2950) provided on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular testing you had on March 30, 2022. 
 
You asked the Plan to pay for the cardiovascular testing. You say that you believe this was denied because the 
service was coded incorrectly. The Plan denied your request. The Plan says services needed for employment 
are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that any services performed due to a third-party 
requirement (such as for employment purposes) are excluded from coverage. Records show that you received 
this cardiovascular testing as a requirement for your employment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardiovascular testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the cardiovascular testing you had on March 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that 10 additional physical therapy sessions are 
needed. The Plan denied your request. The Plan says the requested services have been correctly denied. 
 
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 physical therapy. 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 enrollee's vertigo has improved and she has been transitioned to a 
home exercise program, which has reduced her symptoms. There is no indication that the enrollee continues to 
be incapacitated or unable to perform her daily activities. The enrollee can continue with the home exercise 
program and the skills of a therapist are no longer needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy sessions provided by a participating provider.  
 
The Plan has approved 2 of the requested 10 additional PT sessions. This appeal only addresses the additional 8 
sessions that are being denied.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit (G0439), a urinalysis (81003), an 
electrocardiogram (93000), a glucose blood test (82962) and routine venipuncture (36415) provided on 
September 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an annual wellness visit and services. You say that denied procedures do not 
require an authorization. You also say you have attached supporting documentation that support services. You 
would like the claim re-processed, and payment allowed. The Plan denied your request. The Plan says they 
allow for out of network coverage for emergency services or when there are no in network providers available. 
There are in network providers available. The Plan also says there is no referral letter from an in-network 
physician. 
 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 annual wellness visit (G0439), a urinalysis 
(81003), an electrocardiogram (93000), a glucose blood test (82962) and routine venipuncture (36415) 
provided on September 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays rendered on January 12, 2022. 
 
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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing 
services to a patient who is a registered inpatient shall report the inpatient hospital POS code 21 irrespective of 
the setting where the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. The file does not indicate if the enrollee was inpatient or outpatient; 
therefore, the POS code cannot be supported. 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 
x-rays rendered on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal scaling and root planing 
(D4341) provided on August 30, 2021. 
 
You asked the Plan to waive the coinsurance for scaling and planing. You say that the services were needed, 
and they should be covered. 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 50% 
coinsurance for periodontal scaling and root planing.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$105.50, which is 50% coinsurance of the allowed amount for scaling and planning ($211 allowed amount x 
50% coinsurance = $105.50). Scaling and planing falls within the Dental 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 periodontal scaling and root planing (D4341) provided on August 30, 2021.