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

 
We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910), 
alveoloplasty (D7310), and an immediate mandibular denture (D5140) provided on July 27, 2021. 
 
You asked the Plan to pay for desensitizing medicament, alveoloplasty, and an immediate denture. You say that 
you should not be responsible for this bill. The Plan denied your request. The Plan says the application of 
desensitizing medicament (D9910), alveoloplasty (D7310), and an immediate mandibular denture (D5140) are 
not covered by 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 the 
application of desensitizing medicament (D9910), alveoloplasty (D7310), and an immediate mandibular 
denture (D5140) provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 17, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by your routine 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 
consultation (D9310) provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your doctor recommended a total foot surgery 
because of your severe food condition, but that you are unable to get this surgery due to other health conditions. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
May 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that the enrollee was never 
informed that the phone call would be a telehealth call. The Plan denied your request. The Plan says it was 
confirmed a telehealth visit was rendered; therefore, the proper copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for additional telehealth services with a specialty physician.  
 
The enrollee has been asked to pay a $35 copayment for a specialist telehealth visit. The specialist telehealth 
visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for a specialist telehealth visit provided on May 18, 2022.  Your complaint about your experience with the provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency treatment of dental pain (D9110) provided on 
June 7, 2022. 
 
You asked the Plan to pay for emergency treatment. You say that you did not know that you would have to pay 
for this service. The Plan denied your request. The Plan says emergency treatment of dental pain (D9110) is not 
covered by 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 
emergency treatment of dental pain (D9110) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110) 
and complete lower denture (D5120) provided on May 6, 2022. 
 
You asked the Plan to pay an additional amount for the dental items. You say that you received a bill for $298. 
You say that the rest of this should be paid. The Plan denied your request. The Plan says the annual maximum 
benefit has been exhausted while processing this claim. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the 
annual maximum allowance of $1,000 has been exhausted in the processing of this claim. The record shows 
that the Plan paid $40 for services received on February 11, 2022, $58 for services received on March 18, 2022, 
and $902 towards the dentures in this case. $40 + $58 + $902 = $1,000. The plan contract clearly states that 
after the maxed benefit allowed is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110) and 
complete lower denture (D5120) provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the problem focused limited oral evaluation (D0140) 
provided on May 3, 2022. 
 
You asked the Plan to pre-approve the problem focused limited oral evaluation. You say that you would like 
this service to be covered because it was a necessary treatment. 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 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 
problem focused limited oral evaluation (D0140) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture (D5120), rebase of a 
complete mandibular denture (D5711), surgical placements of implant bodies: endosteal implants (D6010) for 
tooth #'s 22, 25, and 27, and pontic (D6245) provided on September 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that according to the Plan information, if you 
receive services from an out-of-network provider, the reimbursement would be 35 percent. The Plan denied 
your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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. The contract says the enrollee is required to go through a 
predetermination process for all implant-related services. There is no evidence that the enrollee received a 
predetermination for these services. Therefore, we decided that the Plan does not have to pay for the complete 
mandibular denture (D5120), rebase of a complete mandibular denture (D5711), surgical placements of implant 
bodies: endosteal implants (D6010) for tooth #'s 22, 25, and 27, and pontic (D6245) provided on September 14, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), intraoral 
imaging (D0210), and prophylaxis (D1110), provided by an out-of-network provider on November 24, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you thought this provider was in-network. 
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 a comprehensive oral evaluation (D0150), 
intraoral imaging (D0210), and prophylaxis (D1110), provided by an out-of-network provider on November 
24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided by an out-of-network provider on May 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you think the Plan should be paying more 
of this 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 a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided by an out-of-network provider on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service October 12, 
2021. 
 
You asked the Plan to pay for procedure code 93042. You say that no coding changes are required. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 procedure code 93042 billed for date of service October 12, 
2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (81161, 81286, 81413, 81414, 81442, 81479) provided on November 10, 2021.
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration and payment for the denied claim. The Plan denied your request. The Plan says that you failed to submit requested documents.
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 has not given the opportunity for the provider to submit records to support medical necessity. The efforts the plan made are not considered reasonable. Therefore, we decided that the Plan has to pay for laboratory services (81161, 81286, 81413, 81414, 81442, 81479) provided on November 10, 2021.
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 facial photographic images (D0350) and a cone beam 
(D0367) provided on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that these dental procedures 
were not covered by the Plan. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because facial photographic images and the cone beam are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the facial 
photographic images (D0350) and a cone beam (D0367) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4341) provided on May 17, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you needed medication to help numb. You also 
say that you needed a tooth extraction, or you could have other issues. The Plan denied your request. The Plan 
says scaling and root planing is not listed as a covered service. 
 
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 scaling and root planing is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
scaling and root planing (D4341) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic x-
ray (D0330) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or 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 items or services was exhausted on date of service February 24, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
panoramic x-ray (D0330) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided by a participating provider on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 22, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110 and D5120) provided by a participating provider on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313) and 
power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, 
upgrade provided at initial issue (CPT code E2377). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable 
controller and harness) are not medically necessary. They are necessary when there is a medical need to control 
power options though the joystick. The notes do not show a medical need to control the power options through 
the joystick. The power options can be controlled using their own switches. These switches can be made any 
size without asking for a separate request. They can be made from any material without asking for a separate 
request. All of this can be done without the need to use the joystick to control the power features. Also, the 
wheelchair provider did not request the electronic connection to connect the power options to the controller. 
Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessory, harness for 
upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code 
E2313) and power wheelchair accessory, expandable controller, including all related electronics and mounting 
hardware, upgrade provided at initial issue (CPT code E2377).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) additional miles for routine transportation. 
 
You asked the Plan to pre-approve the additional miles for routine transportation. You say that the services are 
necessary. The Plan denied your request. The Plan says the request exceeds the limit listed by your Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Your 2022 EOC states that each 
one-way trip must not exceed 75 miles of driving distance. You are requesting additional mileage for a total of 
85.3 miles (one-way); therefore, this request exceeds your Plan benefits. Therefore, we decided that the Plan 
does not have to pre-approve seven (7) additional miles for routine transportation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found evaluating therapists document that the enrollee would benefit from intense and multi-disciplinary 
rehabilitation; thus, IRF criteria has been met and is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99190, 99191, 99192) provided March 
12, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service is not eligible for payment in the outpatient setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 We find that CPT codes 99190, 99191, and 99192 are not supported in the medical record. Specifically, this 
service is an inpatient only service and is not eligible for outpatient payment. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99190, 99191, 99192) provided March 12, 2022.