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

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #20 provided by an out-of-
network provider on March 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service and 
you would like the Plan to pay your bill. 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 service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is 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 crown (D2740) for tooth #20 provided by an out-of-network provider on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), bitewing x-rays-four 
radiographic images (D0274), and the periodic oral evaluation (D0120) provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the dental cleaning (D1110), bitewing x-rays-four 
radiographic images (D0274), and the periodic oral evaluation (D0120) provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 87640. The Plan denied your request. The Plan says payment for 
code 87640 is bundled into payment for code 87641. 
 
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 87640 is a column II code to column I code 87641. Code 87640 was 
billed with the 59 modifier. The records do not show that the test at issue was separate and distinct testing. 
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 87640 billed for date of service October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic film (D0330) provided on March 9, 2023. 
 
You asked the Plan to pay for the dental service. You say that the x-rays that were done are not the standard x-
rays and they are for a dental appliance. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of November 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic film (D0330) provided on March 9, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not exhausted your benefits. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service December 19, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary and should be 
covered. 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 March 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that 911 was 
called because you experienced a sudden and severe case of shortness of breath. You also say that your 
condition slowly improved and all vital signs returned to normal. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy (G0151) and home health
skilled nursing (G0299 x7).

You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 home health services. Our reviewer
says that the services are not medically reasonable and necessary. Our physician reviewer found physical
therapy documentation dated July 31, 2023, indicated that the enrollee is independent with transfers and
ambulating with a cane. The enrollee is noted to have a wide based gait but is steady. The enrollee is
performing a home exercise program and is at low risk for falling. No physical therapy services were
recommended. The enrollee is medically stable and was not recently hospitalized. The enrollee does not require
wound care, catheterization, G-tube feeding, or administration of intravenous or complex medications. The
enrollee requires some supervision and oversight with medication management, but this does not require skilled
nursing care. The enrollee is independent with mobility and physical therapy was not recommended and was to
be discontinued as of July 31, 2023.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health physical therapy (G0151) and home health skilled nursing (G0299
x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500) provided on April 6, 2023.  
You asked the Plan to pay for disposable contact lenses (S0500). You say that your policy says you get $100 
for glasses and $100 for your new contacts. The Plan denied your request. The Plan says you already received a 
pair of glasses on March 24, 2023. The Plan also says this benefit has been exhausted. 
 
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 a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan says there is a $100 benefit toward the purchase and fitting 
of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The record shows this benefit was 
exhausted on March 24, 2023, as you only are entitled to this benefit once per calendar year. Based on this 
information, we decided that the Plan's rules for coverage of disposable contact lenses (S0500) have not been 
met. Therefore, we decided that the Plan does not have to pay for disposable contact lenses (S0500) provided 
on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81335) provided on February 9, 2023. 
 
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 (81335) provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) and an 
intraorifice barrier (D3911) for tooth #10 and #13 provided on April 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that the denied dental services should be covered by 
the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the treatment of root canal obstruction and an intraorifice barrier 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 
treatment of root canal obstruction (D3331) and an intraorifice barrier (D3911) for tooth #10 and #13 provided 
on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement and osseous contouring of a peri-implant 
defect or defects surrounding a single implant (D6102), bone graft for repair of a peri-implant defect (D6103), 
and the guided tissue regeneration-resorbable barrier, per site (D4266) provided on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the debridement 
and osseous contouring of a peri-implant defect or defects surrounding a single implant (D6102), bone graft for 
repair of a peri-implant defect (D6103), and the guided tissue regeneration-resorbable barrier, per site (D4266) 
provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of a skin substitute (15275, Q4257). 
 
You asked the Plan to pre-approve application of a skin substitute. You say that the requested skin substitute is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested skin substitute 
is experimental/investigational. 
 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 application of a skin substitute. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested skin substitute is an experimental/investigational item/service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of application of a skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve application of a skin substitute (15275, Q4257).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. The Plan denied your request. The Plan says additional 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that you reside in a skilled nursing facility and staff has had 
instruction on maintaining your progress. Additional occupational therapy is not generally accepted as specific 
and effective therapy beyond what was already approved by the Plan. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp cap - indirect (excluding final restoration) (D3120) 
provided on April 6, 2023. 
 
You asked the Plan to pay for the pulp cap - indirect. The Plan denied your request. The Plan says the pulp cap 
- indirect D3120 is not in the dental guide as 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. Therefore, we decided that the Plan does not have to pay for the pulp 
cap - indirect (excluding final restoration) (D3120) provided on April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance crew took your blood pressure and then they left, no transport was given. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on March 28, 2023. 
 
You asked the Plan to pay for the intraoral - periapical each additional radiographic image. You say that you 
looked up your dental coverage for services rendered at in and out-of-network and saw that it would be covered 
at 100%. The Plan denied your request. The Plan says your benefit for the intraoral - periapical each additional 
radiographic image 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 intraoral - periapical each additional radiographic image was exhausted on date of 
service March 28, 2023. You received the allowed frequency of an intraoral x-rays at the same visit. Therefore, 
we decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedures provided on January 11, 2023, billed 
with codes 67966, 97973, 21280, and 21282.  
 
You asked the Plan to pay for the surgical procedures as billed. You say that this should be paid as billed.  The 
Plan denied your request. The Plan says these services are included in the global package for the surgery 
provided on November 21, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say that surgeons who provide unrelated procedures 
during the postoperative period must report modifier -79 to indicate that these are not included in the global 
package of the prior surgery. 
 
We looked at the file and Medicare rules. While the records may support that this was unrelated as the service 
was performed on a different eyelid, the required modifier -79 was not reported for these procedures. Based on 
this information, we decided that Medicare rules for coverage of the surgical procedures as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the surgical procedures provided on January 
11, 2023, billed with codes 67966, 97973, 21280, and 21282.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
expecting a copayment and believe you are entitled to the CT scan for lung cancer screening with $0 
copayment. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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. The total you owe is $125.95, which is less than the standard copayment for 
diagnostic radiology services, including a CT scan. Therefore, we decided that the Plan does not have to waive 
the copayment for a computed tomography (CT) scan provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-intravenous conscious sedation (D9248) provided on 
April 4, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary for you to receive the 
sedation. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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. 
 
  The record shows that the Plan paid $1,568.30 for dental services on March 21, 2023. On April 4, 2023, the 
Plan paid $931.70 for dental services. For the year of 2023 the Plan paid $2,500 ($1,568.30 paid + $931.70 
paid) for dental services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of April 
4, 2023. Therefore, we decided that the Plan does not have to pay for non-intravenous conscious sedation 
(D9248) provided on April 4, 2023.