Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on October 1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you were not the one who called the ambulance. The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $250 copayment for ambulance transportation services. tThis 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 transportation services provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental pontic (code D6245) you received on January 14, 2021. 
 
You asked the Plan to pay for the dental pontic. You say that you thought you were getting a crown. The Plan 
denied your request. The Plan says pontics are not covered under 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 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 dental 
pontic (code D6245) you received on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic substrate (D2740) provided 
September 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denial of $998 as the 
crown fell out and had to be refitted. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in the benefit 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. The health Plan contract says 
that crowns are covered one procedure per tooth every 5 years. The records show that this service was provided 
June 8, 2018, which is within the 5-year time frame limitation. 
 
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 crown - 
porcelain/ceramic substrate (D2740) provided September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the implant supported crown (D6065) and 
unspecified preventive service (D1999) provided on May 12, 2021. 
 
You asked the Plan to reimburse you for the unspecified preventive service. You say that you should be 
reimbursed for the services. The Plan denied your request. The Plan says unspecified preventive service is not 
listed as a covered service. 
 
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 unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse 
you for the implant supported crown (D6065) and unspecified preventive service (D1999) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on September 9, 2021. 
 
You asked the Plan to pay for the Mass spectrometry and tandem mass spectrometry. 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. Medicare rules say that providers must report services correctly. 
 
In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated 
is not separately billable. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) and the cone beam 
computed tomography capture and interpretation (code D0367) you received on November 10, 2021. 
 
You asked the Plan to pay for codes D0140 and D0367. You say that you believe these services should be 
covered. The Plan denied your request. The Plan says for code D0140, you have already received two dental 
exams this year (on dates April 13, 2021, and on October 19, 2021), so you have had exhausted your oral exam 
benefit prior to receiving the services on November 10, 2021.  The Plan says that code D0367 is 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 pay for the 
limited oral exam (code D0140) and the cone beam computed tomography capture and interpretation (code 
D0367) you received on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Column chromatography (82542) and the Mass 
spectrometry and tandem mass spectrometry (83789) provided on March 18, 2021. 
 
You asked the Plan to pay for codes 82542 and 83789. 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. 
 
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 82542 is Column chromatography, includes mass 
spectrometry, if performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. The definition of code 
83789 is Mass spectrometry and tandem mass spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), 
non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. We find that tests to 
confirm that a urine specimen is not adulterated is not separately billable. Therefore, we decided that the Plan 
does not have to pay for the Column chromatography (82542) and the Mass spectrometry and tandem mass 
spectrometry (83789) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on June 23, 2021. 
 
You asked the Plan to pay for code 99053. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the medical services (99053) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (code D0140) you received on October 26, 2021. 
 
You asked the Plan to pay for the oral exam. You say that you were not seen in the office on that day and did 
not have a scheduled appointment.  You said that you had a tooth infection and were seen in the emergency 
department. The Plan denied your request. The Plan says you have exhausted your annual benefit for this 
service.  The Plan says you are only covered for one oral exam (code D0140) per year.  You already received a 
covered oral exam on April 26, 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The medical records clearly show that you had an oral exam on this date. 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 oral exam (code D0140) you received 
on October 26, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the tumor immunohistochemistry testing (88361) provided on August 
12, 2021. 
 
You asked the Plan to pay for the tumor immunohistochemistry testing (88361). You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 
not covered. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered.  
 
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 did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
test code would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Furthermore, the Plan has based their denial on the billing and coding rules 
established in Local Coverage Article (LCA) Billing and Coding: Lab Special Histochemical Stains and 
Immunohistochemical Stains (A57611); however, this LCA does not have jurisdiction in the geographic area 
where the laboratory testing was performed. Therefore, these billing and coding rules do not apply to this 
claim. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for the tumor immunohistochemistry testing (88361) provided on August 12, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225) and a partial lower 
denture (D5226). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that you need 
replacements due to your dog chewing the original partials and you only have 2 teeth for chewing. The Plan 
denied your request. The Plan says the requested services are only covered once per every 5 plan years. 
 
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 a partial 
upper denture and a partial lower denture once every five plan years.  
 
We looked at the file and Medicare rules. The records show that you received an upper partial denture and a 
lower partial denture on June 3, 2021; therefore, you have exhausted your maximum benefit for this service. 
Based on this information, we decided that the Plan's rules for coverage of a partial upper denture and a partial 
lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5225) and a partial lower denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental codes D4921 and D1330 provided on November 8, 2021. 
 
You asked the Plan to pay for dental codes D4921 and D1330. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D4921 and 
D1330 are not covered under the Plan's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D4921 and D1330 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
codes D4921 and D1330 provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multiple dental extractions and alveoloplasty procedures 
provided on May 19, 2021. 
 
You asked the Plan to pay for the multiple dental extractions and alveoloplasty procedures. You say that you 
feel that this should be covered as the enrollee's health required this. The Plan denied your request. The Plan 
says these services are not covered by your dental supplement. A medical claim for these services is being 
reviewed separately. 
 
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 
multiple dental extractions and alveoloplasty procedures provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve out-of-network hearing aids. You say that you were unhappy with the 
hearing aids provided by the in-network provider, and you would like to get hearing aids elsewhere. The Plan 
denied your request. The Plan says hearing aids are only covered when received from a provider in the Plan's 
specified hearing vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from a participating provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of out-of-network hearing aids have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hearing aids (V5261) to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
(70450) provided on October 8, 2021. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
(70450) provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services received on June 7, 2021. 
 
You asked the Plan to pay for the services. You say that you disagree with this decision. The Plan denied your 
request. The Plan says the contract benefit maximum has been applied in this case. 
 
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 crowns and 
bridges with a benefit maximum of $500 per year.  
 
The services done on 6/24/21 paid for $359. The remaining amount of the benefit was paid for this date - any 
charges over the benefit are your responsibility. Based on this information, we decided that the Plan's rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental 
services received on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided from March 26, 2021, to May 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental work provided to you was done 
improperly. The Plan denied your request. The Plan says that The Plan has not supplied any documentation 
regarding their argument for non-coverage of the denied services. 
 
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. Specifically, the case file that the Plan submitted to us for review is substantially 
deficient.  It is missing all of their denial letters and any explanation of their denial rationale.  It is missing any 
applicable contracts or Evidence of Coverage documents for the appropriate year. It is missing any claim 
information for these services.  We have reached out to the Plan multiple times requesting this information in 
order to determine if the Plan's denial was appropriate.  To date, the Plan has failed to provide any of this 
required documentation. Without any of this documentation, we find that the Plan has not met its burden of 
showing why a denial of payment was correct. Therefore, we decided that the Plan has to pay for dental 
services provided from March 26, 2021, to May 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on November 17, 2021. 
 
You asked the Plan to pay for dental code D0274. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0274 is only covered once per 
Plan year. The Plan paid for this code when you received it on May 10, 2021. 
 
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. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states that dental code 
D0274 is only covered once per Plan year. The file shows that the Plan paid for this code when you received it on May 10, 2021. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth (D7210) provided August 
26, 2021 by an out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you were recommended to go to this dentist for 
emergency dental care and you are requesting reimbursement of $750. The Plan denied your request. The Plan 
says enrollee's must receive their dental services from an in-network provider. 
 
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 surgical removal of erupted tooth (D7210) provided August 26, 2021 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement for tooth 20, prefabricated abutment 
for tooth 20, and implant supported porcelain fused to metal crown for tooth 20. 
 
You asked the Plan to pre-approve implant placement for tooth 20, prefabricated abutment for tooth 20, and 
implant supported porcelain fused to metal crown for tooth 20. You say that the services are necessary. The 
Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
implant placement for tooth 20, prefabricated abutment for tooth 20, and implant supported porcelain fused to 
metal crown for tooth 20.