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

 
We decided that the Plan does not have to pay for the filling (D2332) for tooth # 10 provided on December 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you repeatedly made it crystal clear that you only 
wanted work done that would be covered. You say that you received a bill for $212. You also say that this is a 
financial hardship for you. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 and 2 fillings are covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings you received on 
the date of service in this case. Therefore, we decided that the Plan does not have to pay for the filling (D2332) 
for tooth # 10 provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown (D6065 x 2) provided on 
August 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered. You say that a 
crown is a crown no matter how you look at it. You also say that you never would have had it done if the 
dentist did not clear it. The Plan denied your request. The Plan says implants and related services are not covered. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the implant supported crowns are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant supported crown (D6065 x 2) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the handling and/or conveyance of specimen for transfer 
from the office to a laboratory (99000) provided on August 5, 2021. 
 
You asked the Plan to pay for the handling services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this procedure is not paid separately. 
 
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 99000 is handling and/or conveyance of specimen for 
transfer from the office to a laboratory.  
We looked at the file and Medicare rules. In this case, code 99000 has a Status Code of B under the 
Physician Fee Schedule. This Status Code means that payment for covered services are always bundled into 
payment for other services not specified. Based on this information, we decided that Medicare rules for 
coverage of the handling services have not been met. Therefore, we decided that the Plan does not have to pay 
for the handling and/or conveyance of specimen for transfer from the office to a laboratory (99000) provided 
on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on December 1, 2021. 
 
You asked the Plan to pay for dental code D2393. 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. 
 
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 code D2393 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite (D2393) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mouth guard (D9944) provided September 20, 2021. 
 
You asked the Plan to pay for the mouth guard. You say that this item was covered in the past and medically 
necessary. The Plan denied your request. The Plan says this appliance is non-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 a mouth 
guard (D9944) provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 86891, P9022, 99191, 99190, and 99190-76 provided 
on October 27, 2021. 
 
You asked the Plan to pay for codes 86891, P9022, 99191, 99190, and 99190-76. 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 does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for codes 86891, P9022, 99191, 99190, and 99190-76 provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of the Coflex device. 
 
You asked the Plan to pre-approve the placement of the Coflex device. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 pre-approve the placement of the Coflex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Coflex device is experimental. More research is needed to show safety 
and efficacy. 
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 placement of the Coflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the placement of the Coflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120), and obturator 
prosthesis (D5932) provided on July 12, 2021. 
 
You asked the Plan to pay for the dental items. You say that this should be covered under your medical 
coverage. The Plan denied your request. The Plan says the denture and obturator prosthesis are not listed as 
covered dental items. 
 
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 denture and obturator prosthesis 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the complete lower denture (D5120), and obturator prosthesis (D5932) provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950 x 2) provided on October 26, 2021. 
 
You asked the Plan to pay for the 2 core build up. You say that you were not aware that you had broken teeth 
until you contacted the plan in December 2021. You say that crowning broken tooth is normally covered by 
other plans. You say that paying an additional $611 would be a financial burden to you. You also say that you 
would like this claim to be paid. The Plan denied your request. The Plan says core build up are not covered 
services. 
 
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 core build up are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950 x 2) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic you received for tooth #14 (code D6245), and the 
retainer crowns you received for teeth #15 and #13 (code D6740) on September 23, 2021. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that you thought that the dentist did a 
pretreatment estimate but they did not.  You said that you had to have these services because you have bad 
tooth decay. The Plan denied your request. The Plan says these dental services 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 Plans coverage rules apply in this case. The Plan's rules say that only 
those dental services specifically listed in your Evidence of Coverage are covered.  Neither pontics nor retainer 
crowns are listed as covered dental services.  
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 pontic 
you received for tooth #14 (code D6245), and the retainer crowns you received for teeth #15 and #13 (code 
D6740) on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors (A9276). 
 
You asked the Plan to pre-approve CGM sensors. You say that these items have been covered for years. The 
Plan denied your request. The Plan says these items are included in the supply allowance for the enrollee's 
glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that the supply allowance for supplies used with a 
CGM system (K0553, A4238) encompasses all items necessary for the use of the device and includes but is not 
limited to, CGM sensors and transmitters. Supplies or accessories billed separately will be denied as 
unbundling. 
 
We looked at the file and Medicare rules. The requested sensors are included in the CGM supply allowance and 
cannot be separately approved. Based on this information, we decided that Medicare rules for coverage of 
CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor (CGM) sensors (A9276).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the measurement of folic acid in serum (82746) provided on
November 1, 2021.
You asked the Plan to pay for the measurement of folic acid in serum. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says this code exceeded the
maximum units allowed per day.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 82746 is 1. The MAI value for this code is 2. You billed 3 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
measurement of folic acid in serum have not been met. Therefore, we decided that the Plan does not have to
pay for the measurement of folic acid in serum (82746) provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status. You can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support that it is 
medically reasonable and necessary to provide skilled therapy services on a daily basis. As a practical matter, 
the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services provided on October 
29, 2021. 
 
You asked the Plan to waive the copayment for the outpatient services. You say that the treatment you received 
was not a diagnostic procedure and it was coded wrong. The Plan denied your request. The Plan says medical 
records confirmed the enrollee received outpatient services with the provider on the date of service. Therefore, 
the proper copayment was applied. 
 
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 $195 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services.  
 
  You have been asked to pay a $195 copayment for the outpatient services. The outpatient services falls within 
the Outpatient Hospital 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 
the outpatient services provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits provided on October 12, 
2021, and October 20, 2021. 
 
You asked the Plan to waive the copayments for the office visits. You say that you paid the copayment for both 
visits and you should not be charged for it again. The Plan denied your request. The Plan says they reached out 
to the provider and was advised the enrollee did not pay the copayments for the dates of service. Therefore, the 
proper copayments were applied. 
 
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 $5 
copayment per visit for in-network Primary Care Provider. The total copayment amount for both dates of 
service was $10 ($5 copayment per visit x 2 visits). 
 
  You have been asked to pay a $10 copayment for the office visits. The office visits falls within the 
Physician/Practitioner services, including doctors office visits 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 copayments for the office visits provided on October 12, 2021, and October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 31, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were continuously told that a provider 
participated with your plan and then told otherwise at the last minute. You also say that you feel you should not 
be responsible for this bill. The Plan denied your request. The Plan says comprehensive oral exams are covered 
once every 36 months. The Plan also says that the frequency limit has been exceeded. 
 
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 comprehensive oral exams are 
covered once every 36 months, the frequency limit has been exceeded. The record shows that the Plan paid for 
a comprehensive oral evaluation that you received on July 6, 2021. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested services have not been met. 
 
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 pre-approve a transthoracic echocardiography. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that at issue is the appropriateness and medical necessity of a transthoracic 
echocardiography in the absence of any supportive evidence of any symptoms referrable to a cardiac 
abnormality. The enrollee is asymptomatic and exercises extensively. Clinical guidelines do not support 
carrying out a transthoracic echocardiography in this setting. 
 
 
 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 transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography (93306).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you had to go to the ER after having 
surgery that morning due to bleeding from your stiches. You also say this happened because of your surgery 
and are disputing the charges. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 a $90 
copayment for an emergency room visit.  
 The record shows you had an emergency room visit on October 11, 2021. You have been asked to pay a $90 
copayment for an ER visit. An ER visit falls within the Emergency Care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an emergency room (ER) visit provided on October 11, 2021.