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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided by a network 
provider on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was your first visit to this dentist and the 
required oral examination should have been covered. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service March 24, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided by a 
network provider on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation (D0150) and a dental extraction (D7210) 
to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and a dental extraction. You say that you need these services 
to be covered by the Plan and your dentist recommended to see the provider requested. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because an evaluation and a 
dental extraction are not covered by the Plan when performed by an oral surgeon. 
 
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 an 
evaluation (D0150) and a dental extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid tissue regeneration on tooth 
#29 (D3431). 
 
You asked the Plan to pre-approve biologic materials. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says biologic materials to aid tissue regeneration (D3431) are 
not covered by 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 pre-approve 
biologic materials to aid tissue regeneration on tooth #29 (D3431).
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) 
 
You asked the Plan to pre-approve the endosteal implants. You say that you need coverage for these dental 
implants. The Plan denied your request. The Plan says this implant service is not a covered benefit under your 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
surgical placements of implant bodies: endosteal implants (D6010 x2)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950) provided on February 8, 2022, and a 
periapical x-ray (D0220) provided on March 1, 2022. 
 
You asked the Plan to pay for an x-ray and core build up. You say that these services should be covered at 
50%. The Plan denied your request. The Plan says core build up (D2950) is not covered by your dental 
benefits. The Plan also says that your benefit for periapical x-rays (D0220) has 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, core build up is not among those 
covered under this benefit. The record shows your benefit for a periapical x-ray has been exhausted on date of 
service February 8, 2022. Therefore, we decided that the Plan does not have to pay for core build up (D2950) 
provided on February 8, 2022, and a periapical x-ray (D0220) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. 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 February 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit and echo exam 
provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit and echo exam. You say that the echo 
exam should be covered under the specialist office visit copayment. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
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 
copayment for most x-rays and ultrasounds and a $20 copayment per visit to an ophthalmologist or optometrist. 
 
 You have been asked to pay a total of $30 copayment for specialist office visit and echo exam. Echo exams fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The visit to an 
ophthalmologist or optometrist falls within the Vision Care 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 copayment for specialist office visit and echo exam provided on April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 13, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you cannot afford to pay this 
bill. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $440 
copayment for each one-way ground transportation.  
 
You have been asked to pay $213.25 which is less than the standard $440 copayment for ambulance transport. 
Ambulance transport falls within the Transportation 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 copayment for ambulance transport provided on March 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic proton imaging (MRI) of brain (70551) and 
anesthesia (01922) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the imaging services. You say that the enrollee requires sedation due to 
severe claustrophobia. You say that most locations do not offer adult sedation. You also say that the requested 
location offers adult sedation which is medically necessary. The Plan denied your request. The Plan says there 
are in-network providers available to perform these services. The Plan also says they have availability earlier 
than the requested 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 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 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 magnetic proton imaging (MRI) of brain (70551) and anesthesia (01922) to be provided by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
10, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered since 
you were sent back to the hospital because you needed oxygen. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
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 $275 
copayment per member transport for Medicare-covered ground and air ambulance benefits (cost-sharing 
applies per one way).  
 
 
 
 You have been asked to pay $231.89 which is less than the standard $275 copayment for ambulance transport. 
Ambulance transport falls within the Ambulance 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 copayment for ambulance transport provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingivectomies or gingivoplasties (D4211 x2) and a 
complete maxillary overdenture (D5863). 
 
You asked the Plan to pre-approve the gingivectomies or gingivoplasties and complete maxillary overdenture. 
You say that you need teeth/dentures for health reasons. The Plan denied your request. The Plan says these 
services are purely dental in nature, and are unrelated to the limited clinical indications. The Plan also says that 
these services 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 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 two 
gingivectomies or gingivoplasties (D4211 x2) and a complete maxillary overdenture (D5863).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary complete dentures (D5110) and mandibular 
complete dentures (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 6, 2022. 
Therefore, we decided that the Plan does not have to pre-approve maxillary complete dentures (D5110) and 
mandibular complete dentures (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 provided on April 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator. 
 
You asked the Plan to pre-approve a seat elevator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that seat elevators are specifically not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the request is for a power seat elevation 
feature (seat elevator). This item is specifically not covered. Based on this information, we decided that 
Medicare rules for coverage of a seat elevator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat elevator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that on January 1, 2022, you switched 
your medical insurance from Medicare Part B to this Plan. You also say that you provided the facility with your 
new plan information, but they did not inform you that they did not accept the Plan's insurance. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider. The Plan also says 
that the referring provider involved in these services is a non-participating provider with the Plan. The Plan 
also says that they did not authorize any services for the referring or the rendering participator. 
 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 a domiciliary or rest home visit provided on 
February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted molecular pathology procedure (code 
81479) and an unlisted chemistry procedure (code 84999) 
 
You asked the Plan to pre-approve the unlisted molecular pathology procedure and an unlisted chemistry 
procedure. You say that you submitted records to appeal the denied service. The Plan denied your request. The 
Plan says both denied codes are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an unlisted molecular pathology 
procedure (code 81479) and an unlisted chemistry procedure (code 84999) have been met. codes 81479 and 
84999 were requested, but there is not sufficient information in the file to determine what specific testing is 
being requesting under these codes. The provider can submit additional information to the Plan to identify the 
testing of these codes that are representing. Therefore, we decided that the Plan does not have to pre-approve 
an unlisted molecular pathology procedure (code 81479) and an unlisted chemistry procedure (code 84999)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you were expecting a call back. You say that 
you never got one. You also say that you need dentures. The Plan denied your request. The Plan says your 
benefits for the requested dentures have 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 benefits for the requested complete dentures was exhausted on date of service November 4, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9951) and osseous surgery 
(D4261). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says an occlusal 
adjustment (D9951) and osseous surgery (D4261) are not covered under this 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 pre-approve an 
occlusal adjustment (D9951) and osseous surgery (D4261).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 27, 
2022, to February 1, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford to 
pay this. The Plan denied your request. The Plan says the copayment was applied 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 $1475 
for inpatient hospital stay.  
 
You have been asked to pay $1475 ($295/day x 5 days) for an inpatient hospital stay. An inpatient hospital stay 
falls within the Inpatient Hospital Care 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 copayment 
for an inpatient hospital stay from January 27, 2022, to February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code S0020. You say that the services rendered should be paid in full. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for date of service February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional time of moderate sedation provided on 
February 23, 2022, billed with code 99153. 
 
You asked the Plan to pay for the billed code 99153. You say that the claim is for medically necessary services 
and should be paid. The Plan denied your request. The Plan says the services were approved for payment 
except for 99153 as this is not payable in the facility setting. 
 Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is 
not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital 
outpatient departments. 
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional time of moderate sedation provided on February 23, 2022, billed with code 
99153.