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

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) on June 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service provided by a dentist or physician other than requesting dentist or physician (D9310) on 
June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography, the routine exam, and the 
progressive lens provided by an out-of-network provider on September 22, 2022. 
 You asked the Plan to pay for the fundus photography, the routine exam, and the progressive lens. You say that 
you were told by the Plan and the provider that they were in-network. You say if you had known they were out-
of-network you would not have gone. The Plan denied your request. The Plan says the provider was out-of-
network. 
 
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 covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the fundus photography, the routine exam, and the 
progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the fundus 
photography, the routine exam, and the progressive lens provided by an out-of-network provider on September 
22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Simultaneous Pancreas Transplant Listing (48554). 
 
You asked the Plan to pre-approve a Simultaneous Pancreas Transplant Listing. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 Simultaneous Pancreas Transplant 
Listing. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation of frequent labile diabetes mellitus with 
recurrent, acute, and life-threatening episodes of diabetes mellitus (such as severe hypoglycemia or diabetic 
ketoacidosis (DKA)) requiring recurrent hospital admissions or a consistent failure of aggressive insulin 
management. 
 
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 Simultaneous Pancreas Transplant Listing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Simultaneous Pancreas Transplant Listing (48554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 4, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) (codes 
93228 and 93229). 
 
You asked the Plan to pre-approve an MCOT. The Plan denied your request. The Plan says the real-time, 
outpatient cardiac telemetry that you are requesting does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event detection is covered for detection, 
characterization, and documentation of symptomatic transient arrhythmias. 
 
 
 
 
 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 an MCOT. Our physician reviewer 
found the enrollee has weekly palpitations. There is no supportive evidence that the ordering practitioner 
documented any standard, non-MCOT, ambulatory electrocardiogram monitoring. Our reviewer also found that 
there is insufficient documentation to support the medical necessity for an MCOT monitor in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MCOT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a mobile cardiac outpatient telemetry (MCOT) (codes 93228 and 93229).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug injection (Bupivacaine) (J3490) provided on June 3, 
2022. 
 
You asked the Plan to pay for the Bupivacaine. You say that this drug was a medically necessary part of the 
enrollee's procedure. You also say that separate expenses are incurred for this medication. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan follows Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) provides 
the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, postoperative 
visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
 
 
 Review of the file shows that the enrollee had facet joint injections performed on June 3, 2022. The Medicare 
Fee Schedule Data Base (MFSDB) shows that the postoperative period for this code is the day of the 
surgery/procedure. The enrollee received the Bupivacaine injection on June 3, 2022, which is the day of the 
initial procedure. Therefore, this procedure is bundled as part of the global surgical fee because it was reported 
on the same day as the surgical procedure. Therefore, we decided that the Plan does not have to pay for the 
drug injection (Bupivacaine) (J3490) provided on June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 23, 2022, to August 24, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay these charges. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on February 23, 2022, to August 24, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation, osseous surgery, 
adult prophylaxis, and a periodic oral evaluation (D0180, D4260, D4260, D1110, D0120} provided on 
December 16, 2021, to June 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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive periodontal evaluation, osseous surgery, adult prophylaxis, and a periodic oral 
evaluation (D0180, D4260, D4260, D1110, D0120} provided on December 16, 2021, to June 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network pelvic ultrasound provided 
on August 12, 2022. 
 
You asked the Plan to waive the copayment for an in-network pelvic ultrasound. You say that you do not 
understand why you have this large copayment. You need to have this medically done. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $151.69 which is less than the $175 copayment for an in-
network pelvic ultrasound. This item/service falls 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 an in-network pelvic ultrasound provided on 
August 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on July 28, 2022 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the enrollee was not enrolled in hospice on this date of service. The Plan denied your 
request. The Plan says Medicare covers all hospice care from the effective date of election to the date of 
discharge or revocation. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on July 28, 2022
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
July 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $335 
copayment for outpatient hospital observation.  
 
You have been asked to pay $335 copayment for outpatient hospital services. This item/service falls within the 
outpatient hospital observation 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 
outpatient hospital services provided on July 13, 2022.  
 Your complaint about going to emergency room against your wish 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery procedure, bilateral implant 
exchange, right breast revision reconstruction. 
 
You asked the Plan to pre-approve a breast revision reconstruction. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast revision reconstruction. Our 
reviewer says that the service is not medically necessary. Our reviewer found the record indicates that the 
enrollee desires larger implants for cosmetic reasons due to weight gain. The record does not indicate the 
presence of an enumerated condition for which coverage of the requested service is available. 
 
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 breast revision reconstruction have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an outpatient surgery procedure, bilateral implant exchange, right breast 
revision reconstruction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on November 17, 2022. 
 
You asked the Plan to pay for a core build-up. You say that you need these services to get a crown. The Plan 
denied your request. The Plan says this claim has been processed and denied correctly. 
 
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 November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for the COVID-19 tests provided on August 19, 
2022. 
 
You asked the Plan to pay the full cost for the COVID-19 tests. You say that you want to be reimbursed the full 
amount for the COVID-19 tests. You say you did not receive anything in writing stating that the reimbursement 
policy changed. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 tests is an OTC item. Specifically, the Plan paid $12 per test as required by the benefit. Therefore, 
we decided that the Plan does not have to pay the full cost for the COVID-19 tests provided on August 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 26, 
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 limited 
oral evaluation (D0140) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of endosteal implant (D6010) and the 
drugs or medicaments dispensed in the office for home use (D9630) provided on September 7, 2022. 
 
You asked the Plan to pay for the surgical placement of the endosteal implant (D6010) and the drugs or 
medicaments dispensed in the office for home use (D9630). You say that you were told you needed to submit a 
legible Explanation of Benefits from the primary insurance carrier showing the amount paid for each procedure 
code. You say you do not know which carrier primary and which carrier is secondary. 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 pay for the 
surgical placement of endosteal implant (D6010) and the drugs or medicaments dispensed in the office for 
home use (D9630) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180), intraoral - periapical first radiographic image (D0220), and bitewings - four radiographic 
images (D0274) provided on September 9, 2022. 
 You asked the Plan to pay for the dental services. You say that you had a lot of pain in your tooth and had to 
use an out-of-network dentist as an emergency. You also say that your regular dentist office was closed and the 
emergency dentist had to take new x-rays. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted, is not covered or provided by an out-of-network dentist. 
 
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, when services are obtained from an 
out-of-network dentist the Plan only pays up to a certain amount. You are responsible for any amount beyond 
what the Plan pays. The record shows your benefit for the bitewings - four radiographic images (D0274) was 
exhausted on date of service April 7, 2022. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation - new or established patient (D0180), intraoral - periapical first 
radiographic image (D0220), and bitewings - four radiographic images (D0274) provided on September 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99236 provided on August 15, 2022, and code 99235 
provided on August 16, 2022. 
 
You asked the Plan to pay for codes 99236 and 99235. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99236 is observation or inpatient hospital care for 
problems of high severity. The CPT Code Manual definition of code 99235 is observation or inpatient hospital 
care for problems of moderate severity 
 
We find that CPT codes 99236 and 99235 are not supported in the medical record. Although the documentation 
shows provider encounters for the dates of service at issue, the codes billed are not the appropriate codes. 
These codes signify an admission and discharge on the same day. The documentation shows that the enrollee 
was admitted form the emergency room on August 13, 2022. Based on this information, we decided that 
Medicare rules for coverage of codes 99236 and 99235 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99236 provided on August 15, 2022, and code 99235 provided on August 16, 
2022.