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

 
We decided that the Plan does not have to pay for a resin-based composite-two surfaces (D2392) for tooth 
number 3, core buildup (D2950) for tooth number 30, and an amalgam (D2150) provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. You also say that you 
called the provider and were told that they were in-network with the Plan dental vendor. 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 a resin-based composite-two surfaces (D2392) for tooth number 3, core buildup (D2950) for tooth 
number 30, and an amalgam (D2150) provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a tooth filling (D2392) 
provided on October 3, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for this dental service. You say that this is covered 
under your class 2 basic dental coverage. You also say that you should only be charged 50% coinsurance. 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 50% 
coinsurance after $100 deductible for Class 2 Basic Services. Your contract with the Plan also says that white 
fillings on posterior teeth will be processed as a silver filling and the patient is responsible for up to the 
contracted fee.  
 
 You have been asked to pay a $100 deductible toward the cost of the tooth filling. You have also been asked to 
pay a 50% coinsurance on the remaining balance due for the tooth filling (50% x 20.21 = $10.11). This 
item/service falls within the Class 2 Basic Services benefit category. Please note that the Plan contract also says 
that white fillings on posterior teeth will be processed as a silver filling, and you are responsible for up to the 
contracted fee. 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 deductible and coinsurance for a tooth filling (D2392) 
provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower immediate denture (D5140) provided on May 4, 
2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The dental item you are asking the Plan to pay for involves the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the lower immediate denture 
(D5140) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal adjustment services (D9951) provided on September 
19, 2022. 
 
You asked the Plan to pay for the dental 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 fall 
within 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 occlusal 
adjustment services (D9951) provided on September 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided on August 10, 2022, and 
August 24, 2022. 
 
You asked the Plan to pay for aide services. You say that you were told the home health services would be 
covered at 100%. The Plan denied your request. The Plan says that custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of aide services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for home health aide 
services provided on August 10, 2022, and August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on April 22, 2022. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 skilled nursing services have been met. 
Attempts were made to acquire the medical records associated with this appeal with no success. Therefore, we 
decided that the Plan does not have to pay for skilled nursing services provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral x-ray, extraction, nitrous oxide, and oral 
hygiene instructions (D0220, D7210, D1330, D9230) provided on 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the oral hygiene instructions denied correctly as they do not fall within 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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the intraoral x-ray, extraction, nitrous oxide, 
and oral hygiene instructions (D0220, D7210, D1330, D9230) provided on
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 August 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization or referral on file for the services 
rendered. 
 
 
 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 September 26, 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 a core build-up (D2950), and endodontic therapy (D3330) 
provided on February 4, 2022, to October 20, 2022. 
 
You asked the Plan to pay for a core build-up and endodontic therapy. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered 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 a core 
build-up (D2950), and endodontic therapy (D3330) provided on February 4, 2022, to October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you were told that this would be covered. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies, 2 lead, per month (A4595) provided 
on August 21, 2022. 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says that the services are considered experimental and investigational.  
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 pay for the DME. Our physician reviewer found the 
enrollee has chronic neck pain. The enrollee meets the LCD criteria, and the unit is medically reasonable and 
necessary. 
 
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 DME have been met. Therefore, we decided that the Plan has to pay for the 
electrical stimulator supplies, 2 lead, per month (A4595) provided on August 21, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like to appeal due to the 
severity of your injury, pain, and need for physical therapy to unfreeze your broken shoulder. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found your response to therapy and indication for continued therapy is not 
provided. You are able to do a home exercise program. There is no evidence that continued unique input from a 
skilled therapist is medically necessary. Continued strength training does not require skilled input. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON endovenous ablation therapy. You say that the enrollee meets all 
medical necessity criteria for the requested procedure. The Plan denied your request. The Plan says the 
requested OON provided does not provide any specialty that the plan participating provider cannot. The Plan 
says that the participating provider they have referred the enrollee to has appointments available in a week and 
is within the Medicare allowable distance and time from the enrollee's home. 
 
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 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 
endovenous ablation therapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) supply 
allowance (A4595), 
 
You asked the Plan to pay for a TENS supply allowance. You say that please process the attached 
reconsideration. The Plan denied your request. The Plan says that the treatment is deemed experimental and 
investigation by the payer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for a TENS supply allowance. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of chronic neck and back pain due 
to small fibber neuropathy. The enrollee has been treated with medical therapy and physical therapy. The provider recommended treatment with a TENS unit. Indications for use of TENS include patients with acute or 
chronic pain (e.g., postoperative pain, osteoarthritis, diabetic neuropathy, chronic pelvic pain, chronic lower 
back pain, complex regional pain syndrome). Additionally, TENS is used with patients with fibromyalgia and 
spinal cord injury with neuropathic pain. The review has determined that the records do not support that the 
items/services at issue in this case is medically reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TENS supply allowance have not been met. Therefore, we decided that the 
Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) supply allowance (A4595),
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the reports attached support the services provided. 
The Plan denied your request. The Plan says services can be provided by an in-network 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 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 August 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2021, to 
March 9, 2021. 
 
You asked the Plan to pay for the home health services. You say that partial payment was recouped from the 
previously paid claim. You feel that the recoupment should be reconsidered. The Plan denied your request. The 
Plan says no medical records were submitted to support that the recoupment was inappropriate. Medical 
records were requested, but none were received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 home health services have been 
met. No medical records were submitted to support payment of the services at issue despite attempts. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from February 
8, 2021, to March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 71260, 80053, 85025, G0463, 
G1004, Q9967 provided to the enrollee on August 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36415: 
 
Collection of venous blood by venipuncture 
 
CPT 71260: 
 
Computed tomography, thorax, diagnostic; with contrast material(s)  
CPT 80053: 
 
Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total 
(82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) 
Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) 
Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea 
nitrogen (BUN) (84520) 
 
CPT 85025: 
 
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential 
WBC count 
 
Healthcare Common Procedure Coding System (HCPCS) G0463: 
 
Hospital outpatient clinic visit for assessment and management of a patient 
 
HCPCS G1004: 
 
Clinical decision support mechanism national decision support company, as defined by the medicare 
appropriate use criteria program 
 
HCPCS Q9967: 
 
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that with review of the services 
provided, it would not be appropriate to bill all these services on one claim as some of these services were 
provided by different providers. Where there was a radiology procedure done, it was read by the provider and 
would need an appropriate modifier to relate that. Also, the same provider did not do the labs, the lab would get 
those procedures billed to them. The documentation does not support the way these were billed together. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 36415, 71260, 80053, 85025, G0463, G1004, Q9967 provided to the enrollee 
on August 22, 2022.