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

 
We decided that the Plan does not have to pre-approve a resin-based composite-one surface, posterior for tooth 
number 28 (D2391) and porcelain/ceramic pontics for teeth number 23, 24, 25, and 26 (D6245 x 4). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says a resin-based composite-one surface, posterior for 
tooth number 28 is not medically necessary. Additionally, porcelain/ceramic pontics 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. The Plan covers dental items/ 
services that are medically necessary and reasonable.  
  
 
 
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 these dental items. Our reviewer says 
that the request for a resin-based composite-one surface, posterior for tooth number 28 is not medically 
necessary. Our physician reviewer found that the request for a buccal surface restoration has been made for 
tooth number 28. Tooth number 28 is an abutment on a bridge spanning from teeth number 28 to 31. There are 
clinical notes indicating that tooth number 31 needs to be removed from the bridge, saving teeth number 28 and 
29. If there is a defective carious margin on tooth number 28, then it would be appropriate and medically 
necessary to restore the buccal margin in order to save the bridge unit. A letter of necessity or clinical notes 
indicating there was a carious lesion in need of restoration would provide the verification needed to find 
necessity for the requested restoration of tooth number 28 as the defect is not seen on the provided x-rays. 
Additionally, porcelain/ceramic pontics are not covered under the supplemental dental policy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a resin-based composite-one surface, posterior for tooth number 28 (D2391) and 
porcelain/ceramic pontics for teeth number 23, 24, 25, and 26 (D6245 x 4).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on May 22, 2023, to May 29, 2023. 
 
You asked the Plan to pay for a facility visit. You say that the enrollee is in a facility and the facility should 
have obtained the prior authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on May 22, 2023, to May 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on November 22, 2022. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you have enclosed supporting records 
and are requesting a refund. The Plan denied your request. The Plan says the item obtained by the member was 
rendered by a provider who is not part of the Plan hearing vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a provider that was in-network. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and surgical removal of 
residual tooth roots (D7250) provided on May 11, 2023. 
 
You asked the Plan to pay for D0140 and D7250. You say that you were told that you would not owe anything. 
The Plan denied your request. The Plan says the rendered dental services are not covered 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) and surgical removal of residual tooth roots (D7250) provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 additional dental x-rays (D0230) provided on May 23, 
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 May 23, 2023. Therefore, 
we decided that the Plan does not have to pay for 5 additional dental x-rays (D0230) provided on May 23, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray and duplex scan provided on February 07, 
2023, to February 14, 2023. 
 
You asked the Plan to pay for the knee x-ray and duplex scan. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the knee x-ray and 
duplex scan provided on February 07, 2023, to February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are supposed to have to exams a year. 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 May 19, 2023. The Plan 
processes claims as they are received. The claim for March 19, 2023, was processed prior to the claim for May 15, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99204) and fundus photography 
(92250) provided on June 06, 2023. 
 
You asked the Plan to pay for a specialist office visit (99204) and fundus photography (92250). You say that 
the claim denied for no referral on file for this date of service. You also say you have attached medical records 
for reconsideration. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a specialist office visit 
(99204) and fundus photography (92250) provided on June 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of the initial inguinal hernia (49507) provided on 
February 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 payable as the claim was 
submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until June 9, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the repair of the initial inguinal hernia (49507) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6240), and retainer crowns (D6750) provided on 
June 7, 2023. 
 
You asked the Plan to pay for D6240 and D6750. You say that you need the broken bridge removed and fixed. 
The Plan denied your request. The Plan says the denied dental services are not covered 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 pontic 
(D6240), and retainer crowns (D6750) provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on May 8, 2023. 
 
You asked the Plan to pay for D2950. You say that you were told that this was fully covered. The Plan denied 
your request. The Plan says the denied dental service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, cleaning, application of 
fluoride, and oral hygiene instructions (D0120, D1110, D1206, D1330) provided on May 24, 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. Coverage for oral hygiene instructions 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 cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, coverage for oral hygiene instructions denied correctly as they do not fall within your dental 
benefits. Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation, cleaning, 
application of fluoride, and oral hygiene instructions (D0120, D1110, D1206, D1330) provided on May 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on April 03, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for medication assisted 
treatment, and a take home supply of methadone provided on April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided on June 22, 2023. 
 
You asked the Plan to pay for D7210. You say that this was not surgical. The Plan denied your request. The 
Plan says D7210 has been correctly denied. 
 
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 extraction that was provided was a surgical extraction. Therefore, 
we decided that the Plan does not have to pay for a surgical extraction (D7210) provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 24, 2023, 
to May 25, 2023. 
 
You asked the Plan to pay for D0140. You say that this provider was listed as in-network. The Plan denied 
your request. The Plan says these services have been processed 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 limited 
oral evaluation (D0140) provided on May 24, 2023, to May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment provided 
by a chiropractor on April 4, 2023, to April 10, 2023. 
 
You asked the Plan to pay for the extraspinal chiropractic manipulative treatment. You say that you are 
supposed to be covered for all sessions registered in the reimbursement request. The Plan denied your request. 
The Plan says extraspinal chiropractic services are 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 extraspinal chiropractic manipulative treatment provided by a chiropractor 
on April 4, 2023, to April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), collection and 
application of autologous blood concentrate (D7921), osseous graft (D7920), bone graft (D7953) and a fixed 
partial denture (D9120). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 
guided tissue regeneration (D4266), collection and application of autologous blood concentrate (D7921), osseous graft (D7920), bone graft (D7953) and a fixed partial denture (D9120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 24, 
2023. 
 
You asked the Plan to pay for procedure code 93042. You say that you disagree with the Plan's denial. 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 March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver and sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 receiver and sensor. The Plan denied your request. The Plan 
says we may be able to cover this device if a statement from the prescriber is submitted which explains why 
the requested device is medically necessary for treatment outside of the Plan's coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that organizations may limit coverage to certain 
Durable Medical Equipment (DME) brands, items, and supplies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G7 receiver and sensor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G7 receiver and sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 17, 2022, 
to November 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
principal diagnosis A41.9 and secondary diagnosis R65.20 are supported in the documentation, therefore the 
claim should be paid at the DRG originally billed. The Plan denied your request. The Plan says A41.9 and 
R65.20 are not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis R65.20, defined as severe sepsis without septic shock. 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 pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that principal diagnosis A41.9 and secondary diagnosis R65.20 are not 
supported in the documentation. Our physician reviewer found the 92-year-old enrollee presented with altered 
mental status and was admitted with urinary tract infection. They were afebrile, had normal heart rate, and had 
normal blood pressure. The enrollee had leukocytosis with a white blood cell count of 14,000/microliter. 
Criteria for systemic inflammatory response syndrome was not met, so codes A41.9 and R65.20 are not 
supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 17, 2022, to November 21, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal therapy (D3348) provided on March 9, 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 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 Plan's 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 the retreatment of a previous root canal therapy (D3348) provided on March 9, 2023.