Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on December 13, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that we depend on the facility staff to verify eligibility 
and 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 a telehealth visit 
provided on December 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 3, 2022. 
 
You asked the Plan to pay for ambulance services provided on July 3, 2022. You say that the medical records 
provided support the need for the ambulance transport. The Plan denied your request. The Plan says when the 
required additional information is received, we will then process this claim per the enrollee's 2022 benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan confirmed with 
the provider that the claim was submitted to the primary insurance carrier, but they have not provided the 
primary insurance payment information. As the secondary insurer, the Plan cannot be held responsible for 
ambulance services provided on July 3, 2022. until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
the periapical first radiographic image (D0220) provided on December 22, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140) and the intraoral - 
periapical first radiographic image (D0220). You say that the billed charges should be covered. The Plan 
denied your request. The Plan says your benefit for the periapical first radiographic image (D0220) has already 
been exhausted. Limited oral evaluation - problem focused (D0140) is not covered by the Plans 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 limited oral evaluation - problem 
focused (D0140) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periapical first radiographic image (D0220) was exhausted on date of service 
November 16, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - 
problem focused (D0140) and the intraoral - periapical first radiographic image (D0220) provided on 
December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 76140. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry office visit provided on November 10, 2022. 
 
You asked the Plan to pay for a podiatry office visit. You say that you were referred by the emergency 
department to see this provider. 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). There are over 70 podiatrists that are in-network with this Plan. Therefore, we 
decided that the Plan does not have to pay for a podiatry office visit provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infusion with a refilling and maintenance of portable 
pump provided on November 28, 2022. 
 
You asked the Plan to pay for an infusion with a refilling and maintenance of portable pump. You say that this 
should have been covered, please reconsider. 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 infusion with a 
refilling and maintenance of portable pump provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that Medicare covered the CGM and 
supplies for over a year and it will help track your insulin levels. The Plan denied your request. The Plan says 
the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 18, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you forwarded medical records for this case to be 
covered. 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 laboratory testing 
provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5214) provided on December 27, 
2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist accepts Medicare and therefore the 
dental service should be covered under your dental benefits. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the partial lower denture is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial 
lower denture (D5214) provided on December 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 15, 2022, billed with 
code 77002. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is an add on code without an appropriate 
primary procedure. 
 
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 77002 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for imaging services provided on August 15, 2022, billed with code 77002.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 16, 2022, billed with 
code 71045. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 15, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for imaging services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided on 
August 16, 2022, billed with code 71045.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid checks provided from  
April 12, 2022, through November 4, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plans contract states that warranty or service 
costs for hearing aid maintenance are exclusively not covered.  Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aid checks provided 
from April 12, 2022, through November 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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). There are many other providers who are in-network for this patient and are in a close 
proximity to their residence. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, osseous graft, bone replacement 
graft, drugs or medicaments, deep sedation, extraction, and therapeutic parental drugs (D4266, D7950, D7953, 
D9612, D9630, D9222, D9223, D7140) provided on November 2, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Coverage for the guided tissue 
regeneration, osseous graft, bone replacement graft, and drugs or medicaments denied correctly because the 
services 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. 
 
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 guided tissue regeneration, osseous graft, bone replacement graft, drugs or medicaments, deep 
sedation, extraction, and therapeutic parental drugs (D4266, D7950, D7953, D9612, D9630, D9222, D9223, 
D7140) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
tooth #'s 28 and 30 (D2751). 
 
You asked the Plan to pre-approve a crown - porcelain fused tooth #'s 28 and 30 (D2751). The Plan denied 
your request. The Plan says the requested service is not a medical necessity. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown - 
porcelain fused tooth #'s 28 and 30 (D2751) when the services are medically necessary and reasonable.  
 
 
 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 crown - porcelain fused tooth #'s 28 
and 30 (D2751). Our reviewer says that the documentation provided does not meet the criteria for coverage for 
crown restorations (D2751) for teeth #'s 28 and 30. Our physician reviewer found criteria for coverage state 
that there must be significant coronal breakdown due to caries and/or fracture and the bone support of the teeth 
must be adequate. The radiographs provided were not of diagnostic quality for a determination if these criteria 
have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown - porcelain fused tooth #'s 28 and 30 (D2751) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly 
base metal tooth #'s 28 and 30 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aa comprehensive oral evaluation (D0150) provided on 
December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the evaluation was needed prior 
to your tooth being extracted. 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 March 4, 2022. 
Therefore, we decided that the Plan does not have to pay for aa comprehensive oral evaluation (D0150) 
provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) for teeth number 5, 8, 11 (D6011 x 3). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested services 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 services has been exhausted.  Specifically, the Plans contract provides coverage for two dental implants per year. The Plan recently 
approved two dental implants for teeth number 3 and 9. Therefore, you have exhausted the allowable benefit 
for these services at this time. Therefore, we decided that the Plan does not have to pre-approve surgical access 
to an implant body (second stage implant surgery) for teeth number 5, 8, 11 (D6011 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), panoramic 
radiographic image (D0330), resin-based composite - two surfaces, posterior (D2392) provided on December 
8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you haven't seen another provider in three 
years. 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. 
 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 was exhausted on date of service June 4, 
2020. 
 
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 a comprehensive oral evaluation (D0150), 
panoramic radiographic image (D0330), resin-based composite - two surfaces, posterior (D2392) provided on 
December 8, 2022.