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

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental cleaning. You say that you need three cleanings every year, and you 
would like the Plan to make an exception in this case because you have not used your benefit for other services. 
The Plan denied your request. The Plan says you had two previous cleanings in 2021, one in February and one 
in June. Dental cleanings are covered twice per year. The third cleaning provided in November exceeds the 
frequency limitations of your benefit. 
 
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. The Plan can cover two 
standard adult dental cleanings (D1110) per plan year. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning is requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the dental cleaning (D1110) provided on November 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on November 10, 2021.
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed as required by Medicare coding regulations.
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 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2331) provided on December 6, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dentist you saw is listed on the provider 
directory. You say that there are several dentists in the directory that work at the office you went to. You also 
say that this should be cleared up immediately. The Plan denied your request. The Plan says dental services 
received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the filling (D2331) provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravenous infusion and does not have 
to waive the coinsurance for a Medicare Part B drug provided on October 6, 2021. 
 
You asked the Plan to waive the copayment for an intravenous infusion and to waive the coinsurance for a 
Medicare Part B drug.  You say that you cannot afford the high charges and require the injections to treat your condition. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged 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 a $50 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay 5% coinsurance 
for Medicare Part B prescription drugs. 
 
You received an intravenous infusion on October 6, 2021, at an outpatient hospital facility. Therefore, you are 
responsible to pay the $50 copayment.  
 
You received a Medicare Part B drug on October 6, 2021. The total allowed amount is $34,974.60 and 5% of 
that is $1748.73.  
 
The total amount you owe is: $1,798.73.  
 
You have been asked to pay the total amount of $1,798.73 for an intravenous infusion and a Medicare Part B 
drug. An intravenous infusion falls within the outpatient surgery and other medical services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. A Medicare Part B drug falls 
within the Medicare Part B prescription drugs 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 intravenous infusion and does not have to waive the coinsurance for a Medicare Part B drug provided on 
October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported 
porcelain/ceramic crown. You say that since the filling was put in twice and fell off, you feel that these services 
should be covered. The Plan denied your request. The Plan says these services are not covered 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and 
abutment supported porcelain/ceramic crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on August 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that CPT code 99100 is a bundled code. When these services are 
covered, payment for them is subsumed by the payment for the services to which they are incident. 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 anesthesia services provided on August 23, 2021.
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 July 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like the 
Plan to reconsider paying for this service since you had no other choice in the matter. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on July 26, 2021 and your problem focused limited oral evaluation 
(D0140) 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 July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crowns (D2740) provided on October 27, 2021. 
 
You asked the Plan to pay for crowns. You say that you broke your teeth, and therefore these services were 
medically necessary and should be covered. The Plan denied your request. The Plan says Medicare does not 
pay for items or services involving the care, treatment, filling, removal or replacement of teeth or structures 
directly supporting the teeth. The services in question were dental in nature, and are therefore not covered by 
Medicare or your Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve 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 dental crowns (D2740) 
provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve the crown. You say that you need this crown. The Plan denied your request. 
The Plan says that there is no clinical evidence to support medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that you have been 
adequately notified of the Plan's coverage rules and benefits. Also, the dental coverage criteria that was 
submitted by the Plan was dated from 2019. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pre-approve a crown (D2751).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why the claim was denied. 
The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed, the frequency 
limit of once per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation 
that you received on October 7, 2021. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation (D0140) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364), consultation (D9310), and sales tax (D9985) provided on October 20, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, consultation, and sales tax. You 
say that this was a serious infection that needed attention right away and you would like this claim to be 
reconsidered for coverage. The Plan denied your request. The Plan says these services are not covered benefits 
under your dental 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. Medicare rules also say that 
sales taxes are included in the calculation of the Medicare fee schedule. 
 
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 cone 
beam computed tomography (CT) capture and interpretation (D0364), consultation (D9310), and sales tax 
(D9985) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two sinus augmentations with bone or bone substitutes 
(D7951 x2). 
 
You asked the Plan to pre-approve the sinus augmentations. You say that you would like to appeal these 
services. The Plan denied your request. The Plan says this service is not covered under your benefit 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
sinus augmentations with bone or bone substitutes (D7951 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic propulsion tires (E2213, E2211) and transport brackets (K0108).
You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan denied your request. The Plan says this equipment is not considered durable medical equipment.
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 wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical notes from the enrollee's treating provider do not document why the standard tires which come with the wheelchair are inadequate for meeting his needs with regard to mobility related activities of daily living within the home. Additionally, the provided records do not document that the transport brackets serve a medical purpose inside the enrollee's home. The brackets are requested for transportation outside the home. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic propulsion tires (E2213, E2211) and transport brackets (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650) and shoulder immobilizer (L3670), 
provided on September 27, 2021. 
 
You asked the Plan to pay for the back brace and shoulder immobilizer. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the supplier made an unsolicited telephone contact to 
this member to provide these items. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the back brace and 
shoulder immobilizer have not been met. Therefore, we decided that the Plan does not have to pay for the back 
brace (L0650) and shoulder immobilizer (L3670), provided on September 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) 
test (78452) provided on August 9, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that the services should be covered as 
you were under the impression the copayment would be lower. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $200 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $200 copayment for a SPECT test. SPECT tests fall within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 a myocardial perfusion imaging (SPECT) test (78452) provided on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on July 1, 2021. 
 You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 99291 
and 31500. 
 
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 99291 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services (99291) provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), additional 
intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on November 11, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, additional intraoral periapical x-ray, and 
panoramic x-ray. You say that you would like to appeal these services. The Plan denied your request. The Plan 
says your benefits for these services have been satisfied and the frequency limitations have 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, periodontal exam and comprehensive 
oral evaluation share a frequency limitation of one procedure code every three years. The record shows that 
you received a comprehensive periodontal evaluation (D0180) on February 18, 2019 and your periodontal 
exam and comprehensive oral evaluation benefit has been exhausted. The contract says that intraoral x-rays are 
limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical 
x-ray (D0220) on November 11, 2021 and your intraoral x-rays benefit has been exhausted. The contract also 
says that full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows 
that you received a panoramic x-ray (D0330) on February 18, 2019 and your full mouth or panoramic x-rays 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided 
on November 11, 2021.  
 
Your complaint about being provided with dishonest treatment is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 82306, 84443, 
85025) provided on September 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that it was not known that the doctor was out-of-
network and prior authorization needed to be obtained. You also say that there was no indication on the 
member card that prior authorization was needed. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider, and the rendering provider is a non-participating provider. The Plan 
also says that the referring provider involved in these services is a non-participating provider with the Plan, and 
they did not authorize any services for this provider or for the facility. 
 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 laboratory services (36415, 80053, 80061, 82306, 
84443, 85025) provided on September 13, 2021, by an out-of-network (OON) provider.