Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for a portable oxygen concentrator 
provided on October 29,2021. 
 
You asked the Plan to increase the reimbursement for a portable oxygen concentrator. You say that you were 
told the insurance company would pay 80% of the portable oxygen machine. The Plan denied your request. The 
Plan says you have been reimbursed the correct 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 20% 
coinsurance for durable medical equipment.  
 
According to Medicare you are reimbursed 80% of the allowed amount for a portable oxygen concentrator, not 
80% of the total amount you paid. You have been asked to pay $106.96, which is 20% coinsurance of the allowed amount for a portable oxygen concentrator ($534.82 allowed amount x 20% coinsurance = $106.96). 
You have been reimbursed $427.86 ($534.82 allowed amount - $106.96 coinsurance = $427.86). A portable 
oxygen concentrator falls within the Durable Medical Equipment (DME) and Related Supplies benefit 
category. This means that you have been reimbursed 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 increase the reimbursement for a portable oxygen concentrator provided 
on October 29,2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 20, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel will guide appropriate medical 
management of the enrollee. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 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 the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the gene panel testing provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on February 3, 2022. 
 
You asked the Plan to pay for the simple extraction. You say that you had an erupted tooth and an infection that 
required the extraction, as you needed surgery and had to resolve the issue beforehand. The Plan denied your 
request. The Plan says this service is not covered. The Plan also says that you were not enrolled in the 
supplemental dental plan at the time of service. 
 
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 simple 
extraction (D7140) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), pulp vitality test 
(D0460), and root canal (D3320) provided on November 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as an extension 
of your medical coverage. You say that the services were needed as a result of the radiation treatments for your 
tongue cancer. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The 
Plan says that the frequency limit has been exceeded. The Plan also says that the annual maximum benefit of 
$1,000 has been reached. 
 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 and 2 exams are covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you 
received on July 19, 2021, and November 8, 2021. Additionally, the record shows that the annual maximum 
benefit of $1,000 has been exceeded.  
 
Date of Service Plan Paid 
4/15/2021 $58 
7/19/2021 $150 
9/7/2021 $209 
10/5/2021 $209 
11/8/2021 $178 
11/22/2021 $184 
12/13/2021 $112 
TOTAL: $1,000 
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), pulp vitality 
test (D0460), and root canal (D3320) provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service rendered due to an emergency case and 
the treatment provided to the enrollee was medically necessary. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 December 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81235, 
and 81321) provided on September 19, 2021.  
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81235, and 
81321) provided on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital visits provided from September 16, 2021, through September 28, 2021.
You asked the Plan to pay for inpatient hospital visits. The Plan denied your request. The Plan says authorization was not obtained.
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 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 inpatient hospital visits provided from September 16, 2021, through September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiographic/surgical implant index (D6190) provided on 
March 8, 2022. 
 
You asked the Plan to pay for the radiographic/surgical implant index. You say that you would like the Plan to 
consider paying for services related to implants as the tooth being replaced is a front tooth and you do not want 
dentures. The Plan denied your request. The Plan says this service is 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 pay for the 
radiographic/surgical implant index (D6190) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services (99239) provided on July 7, 2021. 
 
You asked the Plan to pay for the hospital discharge services. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this code is not 
supported in the medical documentation. 
 
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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 We find that CPT code 99239 is not supported in the medical record. Specifically, there is no confirmation in 
the medical records that were submitted that more than 30 minutes was spent on hospital discharge day 
management services. Based on this information, we decided that Medicare rules for coverage of the hospital 
discharge services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge services (99239) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) 
provided October 15, 2021. 
 
You asked the Plan to pay for the white filling for a back tooth. You say that this service was a necessary part 
of your root canal. The Plan denied your request. The Plan says this service is not covered under your 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 resin-
based composite - one surface, posterior (D2391) provided October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen equipment (E0443, E0431, E1390). 
 
You asked the Plan to pre-approve home oxygen equipment. You say that this is medically necessary for the 
enrollee's medical condition. The Plan denied your request. The Plan says the criteria for home oxygen therapy 
have not been met. 
 
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 home oxygen equipment (E0443, 
E0431, E1390), have been met. In this case, no medical records have been provided to indicate the enrollee 
would qualify for the requested oxygen equipment. Therefore, we decided that the Plan does not have to pre-
approve home oxygen equipment (E0443, E0431, E1390).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (predominantly 
base metal) (D6063). 
 
You asked the Plan to pre-approve abutment supported cast metal crowns. You say that you need this service. 
The Plan denied your request. The Plan says this service is not covered under your 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 
abutment supported cast metal crowns (predominantly base metal) (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2740 x2) and inhalation of nitrous 
oxide/analgesia (D9230) provided on December 20, 2021. 
 
You asked the Plan to pay for the crowns and inhalation of nitrous oxide/analgesia. You say that the limit of 
some procedures was not made clear. You also say that if you had known, these services could have been 
postponed. The Plan denied your request. The Plan says you have exceeded the limit for the crowns prior to 
this date of service. The Plan also says that the anesthesia services were not performed in connection with a 
covered surgical procedure. 
 
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, you are limited to 2 crowns per 12 
consecutive months. The record shows that you received two crowns (D2790 x2) on March 23, 2021 and your 
crowns benefit has been exhausted. The anesthesia is therefore not covered because these crowns are not 
covered. Therefore, we decided that the Plan does not have to pay for the two crowns (D2740 x2) and 
inhalation of nitrous oxide/analgesia (D9230) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. In addition, the 
documentation also does not provide evidence that you would be able to safely operate the PMD. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 27, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell in the bathtub. You say that you 
were not able to get up on your own. You say that 2 firemen showed up to help you and then left. You also say 
that at no time did an ambulance show up. The Plan denied your request. The Plan says since there was no 
transport provided, there is not a payable service. 
 
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 November 27, 2021. 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 response and treatment, no 
transport, (A0998) provided on November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on December 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that medical records provide evidence of medical 
necessity. The Plan denied your request. The Plan says the code was not billed with an appropriate place of 
service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim provided lists a place of service as 22, a hospital outpatient. No 
payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 January 25, 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 the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this device is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered. 
 
We looked at the file and Medicare rules. In this case, the Volara system includes an IPV device. Based on this 
information, we decided that Medicare rules for coverage of the Volara system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 21, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that this 
service should be covered because you have another claim and think it will not be covered as well. The Plan 
denied your request. The Plan says this procedure exceeds the frequency limitations 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, emergency oral evaluation problem 
focused exams are covered once every 12 months. The record shows that you received a problem focused 
limited oral evaluation (D0140) on November 23, 2021 and your emergency oral evaluation problem focused 
exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on January 21, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that these services were medically necessary. 
You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit 
limit for D0140 has already been met and 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. The Plan covers one limited 
oral evaluation per plan year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided 
on January 4, 2022. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided by a participating provider on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) services. 
 
You asked the Plan to pre-approve the PET scan. You say that the clinical documentation provided supports the 
need for the requested PET scan. The Plan denied your request. The Plan says there is no documented mini 
mental status exam or similar test score, result of any prior imaging, results of neuropsychological testing, or 
any relevant lab tests to support the criteria having been met for coverage of the requested PET scan. 
 
The Plan follows Medicare rules. Medicare rules say that a PET/CT scan of the brain done for dementia is 
limited to those patients for whom differential diagnosis of fronto-temporal dementia (FTD) and Alzheimers 
disease (AD) under specific requirement. 
 
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 PET scan. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee is not noted to meet 
diagnostic criteria for either AD or FTD. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) services.