Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. You also say that you would like this to be reconsidered for processing. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on May 25, 2022. 
 
You asked the Plan to pay for a core build-up. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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) provided on May 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 14, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the claim was denied, stating the enrollee was 
enrolled in hospice at the time of transport. You say that the enrollee was not enrolled in hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on September 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
June 28, 2022. 
 You asked the Plan to pay for procedure codes 20936 and 20930. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says procedure codes 20936 and 
20930 are considered bundled and not separately payable. 
 
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 codes 20936 and 20930 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid provided on May 24, 2022. 
 
You asked the Plan to pay for a hearing aid. You say that the hearing aid should be covered under your $1,500 
allowance. The Plan denied your request. The Plan says per the EOC, you have supplemental insurance that 
covers one hearing aid every three years. The Plan also said they approved/paid for a pair of hearing aids you 
purchased on April 28, 2022. 
 
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. The Plan pays for 
hearing aids only once every three years.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for a 
hearing aid provided on May 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on September 7, 2022. 
 
You asked the Plan to pay for the transportation services. You say that this charge is associated with the 
expense of needing transportation home from the hospital, which was approximately an hour and a half away 
from where you reside. The Plan denied your request. The Plan says the transportation company you used is 
not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation services have not been met. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on September 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on April 11, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the records attached support the 
services provided 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 skilled nursing facility 
visit provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 3, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite fillings (D2331, D2335) and a 
panoramic x-ray (D0330) provided on February 28, 2019. 
 
You asked the Plan to pay for the fillings and x-ray. You say that you just recently found out that you had 
dental coverage. The Plan denied your request. The Plan says that the dental claim was submitted past the 
timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the fillings and x-ray was not filed until September 14, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the resin-based composite fillings (D2331, D2335) and a 
panoramic x-ray (D0330) provided on February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flu immunizations provided on September 13, 2022. 
 
You asked the Plan to pay for flu immunizations. You say that a primary care provider referral should not be 
required 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 flu immunizations 
provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingivectomy or gingivoplasty to allow access for 
restorative procedure per tooth #4, #5, #6, #7, #8, #9, #10 (D4212). 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty to allow access for restorative procedure 
per tooth #4, #5, #6, #7, #8, #9, #10 (D4212). You say that you are appealing these services. The Plan denied 
your request. The Plan says the 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 pre-approve the 
gingivectomy or gingivoplasty to allow access for restorative procedure per tooth #4, #5, #6, #7, #8, #9, #10 
(D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, bitewing x-rays, and periodic oral evaluation 
(D1110, D0274, D0120) provided on August 3, 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 a 
cleaning, bitewing x-rays, and periodic oral evaluation (D1110, D0274, D0120) provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), panoramic x-ray (D0330), and 
prophylaxis (D1110) provided on January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that no one advised that you would be 
responsible for the remaining balance with the provider. You also say that you cannot afford to pay the bill. 
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. 
 
 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 comprehensive oral evaluation (D0150), 
first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), panoramic x-ray (D0330), 
and prophylaxis (D1110) provided on January 6, 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 detailed and extensive oral evaluation, intraoral x-ray, 
diagnostic casts, and local anesthesia (D0210, D9215, D0470, D0160) provided on March 22, 2019, to October 
2, 2019. 
 
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 claim was not filed timely and you did not 
have dental benefits until 2020 so they would not have been covered even if the claim was filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until October 31, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a detailed and extensive oral evaluation, intraoral x-ray, 
diagnostic casts, and local anesthesia (D0210, D9215, D0470, D0160) provided on March 22, 2019, to October 
2, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) provided on 
August 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee should not be 
penalized for having received medically necessary treatment. You also say that you would like the denied 
charges to be reconsidered. The Plan denied your request. The Plan says these services were rendered by a non-
network provider, and the services were not referred by a network provider. The Plan also says that these 
services are not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 the domiciliary or rest home visit (99334) 
provided on August 30, 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 the limited oral evaluation (D0140) provided on November 
7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you needed the consultation so the dentist could 
determine treatment for the repair of your broken crown. 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 January 20, 2022, and 
July 20, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) 
provided on November 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for propietary laboratory imaging provided on October 26, 2022. 
 
You asked the Plan to pay for propietary laboratory imaging. You say that the records attached support the 
services provided 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 propietary laboratory 
imaging provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on September 8, 2022. 
 
You asked the Plan to pay for the consultation. You say that your expectation is that when you seek treatment 
from an in-network dentist, the dentist will perform services sanctioned within the provisions of your plan. You 
also say that you expect to be advised by the provider if services, treatments, and medicines provided may not 
be allowed under your plan. The Plan denied your request. The Plan says this service is not covered under 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) provided on September 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is noted to have a PEG for feeding and 
a trach for respiration. They have been getting total care. The enrollee has been receiving passive therapy. This 
is a request for Skilled Nursing Facility level of care due to brain damage. The Plan denied your request. The 
Plan says the enrollee is in continued need of care, but this care should be delivered at a lower level due to the 
member's condition.  
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lenses purchased on August 1, 2022. 
 
You asked the Plan to pay for the bifocal lenses. You say that you never requested a medical test, as you trust 
the provider gave you the medical services you needed. You also say that you purchased a number of glasses 
from this provider over time. The Plan denied your request. The Plan says the benefit maximum for this time 
period or occurrence has been reached. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan will pay up to $175 toward the purchase of eyeglasses for your routine vision correction 
needs. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan paid the full eyeglasses 
allowance of $175 on this date of service, and your eyewear allowance has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the bifocal lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for the bifocal lenses purchased on August 1, 2022.