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

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on April 6, 
2023. 
 
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 March 10, 2021. 
Therefore, we decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on 
April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 12, 2022, billed 
with codes 81295, 81294, 81297, 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 12, 2022, billed with codes 81295, 81294, 81297, 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) for tooth 
#25, the dental implant removal (D6100) for tooth #22, and the analgesia (D9230) provided on March 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that your dental procedures 
would not be approved, and they were medically necessary. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the periodontal scaling and root planing, the dental 
implant removal, and the analgesia 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 
periodontal scaling and root planing (D4342) for tooth #25, the dental implant removal (D6100) for tooth #22, 
and the analgesia (D9230) provided on March 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you and your husband 
are both on permanent disability and have very limited income. 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 $290 
copayment for in and out-of-network ground ambulance service regardless of the number of trips.  
 
 You have been asked to pay a $290 copayment for the ambulance transport. This service falls within the in 
ambulance services 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 ambulance transport 
provided on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyeglass lenses (V2102) provided on March 17, 2023. 
 You asked the Plan to reimburse for eyeglass lenses (V2102). You say that you are within the $350 allowance 
laid out (nowhere near exhausted). The Plan denied your request. The Plan says your $350 eyewear benefit 
allowance was exhausted with your second purchase on March 17, 2023. 
 
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 $350 allowance every calendar year that you can use to pay for eyewear to correct 
vision. 
 
We looked at the file and the Plan's rules. The Plan rules say they provide a $350 allowance every calendar 
year that you can use to pay for eyewear to correct vision. The record shows this benefit was exhausted on 
March 14, 2023, and March 17, 2023. Based on this information, we decided that the Plan's rules for coverage 
of eyeglass lenses (V2102) have not been met. Therefore, we decided that the Plan does not have to reimburse 
for eyeglass lenses (V2102) provided on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation, incomplete endodontic 
therapy, and cone beam CT scans (D0140, D3332, D0364) provided on March 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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. Cone beam CT scans 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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This benefit does not include cone beam computed tomography (CT) scans. 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 limited oral evaluation, incomplete endodontic therapy, and cone beam CT 
scans (D0140, D3332, D0364) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on March 9, 2023. 
 
You asked the Plan to pay for the prophylaxis - adult. You say that you were not advised that the provider was 
out-of-network until after services were rendered. 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 prophylaxis - adult (D1110) provided on March 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration 
provided on March 23, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and administration. You say that you 
disagree with the coinsurance assessed to the claim. 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 40% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 40% coinsurance for chemotherapy drugs and administration. This item/service 
falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The total you owe is $588.02, which is 40% of the allowed 
amount for chemotherapy drugs and the administration of the drugs performed by an out-of-network provider 
($1,470.05 allowed x 40% = $588.02). Therefore, we decided that the Plan does not have to waive the 
coinsurance for chemotherapy drugs and administration provided on March 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided on July 11, 
2022, to August 25, 2022. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you would like a refund on the 
excessive charges for your radiation treatment. 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 20% 
coinsurance for outpatient diagnostic test. 
 
You have been asked to pay 20% coinsurance for radiation therapy. This item/service falls within the outpatient 
diagnostic test 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 coinsurance for radiation therapy provided 
on July 11, 2022, to August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 16, 2023. 
 
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.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) for tooth #15 provided on 
May 18, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were told the Plan covers dental work and it 
now says you do not have coverage for fillings, but it was for something else. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because the resin-based composite is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2392) for tooth #15 provided on May 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 17, 2022, to August 24, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the services should be fully 
covered for 20 days. 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 $280 
copayment per day for days 1-6 for inpatient hospital care.  
 
 
  The record shows you were in the hospital for 7 days from August 17, 2022, to August 24, 2022. Therefore, 
you have been asked to pay a $280 copayment per day for days 1-6 for the inpatient care. The total for your 
stay is $1,680 ($280 copayment x 6 days = $1,680). This item/service falls within the inpatient hospital care 
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 inpatient hospital care provided 
from August 17, 2022, to August 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine ambulance supplies provided on February 24, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that you needed medical assistance due to the 
mental state you were in from physical force by a police officer. The Plan denied your request. The Plan says 
this item is not a Medicare covered benefit and excluded from coverage under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for routine ambulance supplies provided on February 24, 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 December 29, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
submitted records support the medical necessity. 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 December 29, 2021. 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 December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on April 19, 2023. 
 
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 November 30, 2022. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis treatments (A4913, 82374, 82310, 82040) provided 
on December 2, 2022 to December 30, 2022. 
 
You asked the Plan to pay for the dialysis treatments. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 A4913, 82374, 82310, & 82040 are not supported in the medical record. Specifically, 
the required JA or JB modifier was not billed. Based on this information, we decided that Medicare rules for 
coverage of the dialysis treatments have not been met. Therefore, we decided that the Plan does not have to pay 
for dialysis treatments (A4913, 82374, 82310, 82040) provided on December 2, 2022 to December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have no assistance at home and are unable to 
care for yourself. You say you are a fall risk and the requested IRF services are necessary for you to be able to 
walk. The Plan denied your request. The Plan says  you do not meet Medicare guidelines for services in an IRF.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided on July 1, 2021. 
 
You asked the Plan to pay for limited oral evaluation and intraoral - periapical first radiographic image. You 
say that this should be covered. The Plan denied your request. The Plan says this is not 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited 
oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided 
on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on March 16, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you do not 
understand why you have a 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for a magnetic resonance image (MRI). 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
magnetic resonance image (MRI) provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says the 
information provided by your doctor indicates that you do not currently have any of the conditions to meet 
coverage criteria. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported porcelain/ceramic crown on tooth 15 and 
18 (D6065) and custom abutment on tooth 15 and 18 (D6057) provided on March 27, 2023. 
 
You asked the Plan to pay for implant supported porcelain/ceramic crown and a custom abutment. You say that 
this should be covered. The Plan denied your request. The Plan says this is not 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
supported porcelain/ceramic crown on tooth 15 and 18 (D6065) and custom abutment on tooth 15 and 18 
(D6057) provided on March 27, 2023.