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

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation (D0150). You say that you need a 
periodontist for your gums. The Plan denied your request. The Plan says services performed by a periodontist 
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 a 
comprehensive oral evaluation (D0150).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services 
 
You asked the Plan to pre-approve the imaging 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 meet the clinical requirements to be approved. 
 
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 the imaging services have been met. 
We have not received any medical records from the plan and without them we are unable to determine whether 
the imaging services are medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
imaging services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on September 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you never saw the provider before so the benefit 
should not be exhausted. 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 the date of service of August 31, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided on September 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2022. 
 
You asked the Plan to pay for an office visit. You say that the facility failed to obtain authorization. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction and the contact lens fitting provided by an out-
of-network provider from March 2, 2021, to March 16, 2021. 
 You asked the Plan to pay for the refraction and the contact lens fitting. You say that you are appealing this 
denial. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 covers these services when you may see any licensed vision provider who accepts Medicare 
patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and the Plan's rules. Specifically, the provider did not choose to receive Medicare funds. 
This means the provider is on the Medicare opt-out list. Based on this information, we decided that the Plan's 
rules for coverage of the refraction and the contact lens fitting have not been met. Therefore, we decided that 
the Plan does not have to pay for the refraction and the contact lens fitting provided by an out-of-network 
provider from March 2, 2021, to March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services 
 
You asked the Plan to pre-approve imaging 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 meet the clinical requirements to be approved. 
 
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 imaging services have been met. We 
have not received any medical records from the plan and without them we are unable to determine whether the 
imaging services are medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
imaging services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0621), progressive lenses (V2781) and deluxe frames (V2025) provided June 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the routine eye exam and refraction, progressive lenses and deluxe frames. You 
say that your glasses were cheaper at the OON provider. The Plan denied your request. The Plan says routine 
vision services are not covered OON. 
 
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 covers these services when provided by a vision network provider. 
 
We looked at the file and the Plan's rules. In this case the vision services were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the routine eye exam and refraction, progressive 
lenses and deluxe frames have not been met. Therefore, we decided that the Plan does not have to pay for the 
routine ophthalmological examination including refraction (S0621), progressive lenses (V2781) and deluxe 
frames (V2025) provided June 29, 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 the panoramic x-ray (D0330) provided on August 25, 2022. 
 
You asked the Plan to pay for the panoramic x-ray (D0330). You say that the x-ray was needed to assist in 
diagnosing suspected dental disease. You say the schedule of benefits does not state that the panoramic images 
are not covered. 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 panoramic x-ray (D0330) is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) provided on August 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for an ambulance service on June 15, 
2022. 
 
You asked the Plan to waive the $250 copayment for ambulance service. You say that you cannot afford to pay 
the copayment. 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 a $250 
copayment for ambulance service.  
 
You have been asked to pay a $250 copayment for ambulance service. This item/service falls within the 
ambulance service 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 $250 copayment for an ambulance 
service on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting an appeal due to the 
patient only has two teeth left. You also say that the patient is not able to eat/chew her food properly without a 
mandibular denture. 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 November 25, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eye exam, eye refraction, progressive lens, and 
frames provided on July 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the eye exam, eye refraction, progressive lens, and frames. You say that 
you would like to appeal the amount of $180.00 that was not covered because it was coded incorrectly. The 
Plan denied your request. The Plan says because the provider is out-of-network, these claims processed 
correctly. The Plan also says both claims were billed with routine diagnosis codes, and do not get processed 
through medical. 
 
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. 
 
 
 
 We looked at the file and the Plan's rules. The contract clearly states that you are responsible for any amount 
over $75 for a routine eye exam that is rendered by an out-of-network provider, and you are also responsible 
for any amount over the $100 retail price for frames and lenses purchased from an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam, eye refraction, 
progressive lens, and frames have not been met. Therefore, we decided that the Plan does not have to pay more 
for the eye exam, eye refraction, progressive lens, and frames provided on July 27, 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 the dental services provided on September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a notice that the dentist is not in-
network. You also say you found him on the Plan's dental website and would like to see this claim is processed 
as in-network. 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 the dental services provided on September 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided on June 30, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were unrelated to the enrollee's 
terminal condition. The Plan denied your request. The Plan says Original Medicare is responsible for coverage. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 We looked at the file and the rules. The enrollee was under the Medicare hospice benefit for the dates of 
service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient 
therapy services provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment 
for code 64447. 
 
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 93010 
is a column II code to column I code 64447. 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 procedure code 93010 billed for date of service July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography (92250) provided on August 18, 2022. 
 
You asked the Plan to pay for fundus photography (92250). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says according to your 2022 EOC, your plan does not cover 
fundus photography with interpretation and report. 
 
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 fundus 
photography (92250) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing x-
rays provided on October 4, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were told by multiple people that this 
treating provider was in-network. 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 the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on October 4, 2022, by an 
out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established 
patient (D0150), panoramic radiographic image (D0330), complete denture - maxillary (D5110), and 
mandibular partial denture - cast metal framework with resin denture bases (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures are too big and cannot be 
resized. You also say that you are having pain and difficulty eating. The Plan denied your request. The Plan 
says your benefit for the requested items or services 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 benefit for the comprehensive oral evaluation (D0150), and panoramic radiographic image (D0330) 
was exhausted on date of service July 28, 2020.  The record also shows your benefit for the complete denture - 
maxillary (D5110) was exhausted on October 14, 2020, and the mandibular partial denture (D5214) was 
exhausted on September 2, 2020. 
 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or 
established patient (D0150), panoramic radiographic image (D0330), complete denture - maxillary (D5110), 
and mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service September 
18, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service September 18, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 22, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 a $170 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $170 copayment for an ultrasound. However, you are only being asked to pay 
$122.60 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic 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 an ultrasound provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 5, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 5, 2022.