Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided on February 27, 2023. 
 
You asked the Plan to pay for Infrared light therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
 We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown for tooth 7 
(D2750). 
 
You asked the Plan to pre-approve the dental services. You say that it's hard to chew and bite down so it's 
necessary to have a tooth there. 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 September 17, 2019. 
Therefore, we decided that the Plan does not have to pre-approve white glass with high gold content crown for tooth 7 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93220 billed for date of service September 30, 2021. 
 
You asked the Plan to pay for code 93220. You say that this claim is billed correctly. The Plan denied your 
request. The Plan says code 93220 is not supported by the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit for reimbursement consideration. Healthcare plan denied payment for documentation does not support service billed. 
 
We asked our coder 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 code 93220. Our reviewer says that code 93220 is not 
supported by the medical record. Our reviewer found the medical records document "Advised admission for 
further stroke work-up". In this case, observation care is not documented and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 93220 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93220 billed for date of service September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2023. 
 
You asked the Plan to pay for the office visit . You say that you do not understand why this service was denied. 
You say you had an eye infection and a referral from your primary care physician. The Plan denied your 
request. The Plan says they did not receive a valid itemized receipt and the Plan could not determine which 
services were paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit have been met. The 
itemized receipt was illegible. Therefore, we decided that the Plan does not have to pay for the office visit 
provided on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad (E0217) provided from 
January 1, 2023, to January 9, 2023. 
 You asked the Plan to pay for the water circulating heat pad. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says this item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the water circulating heat pad. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no clinical need in this case for a water heat pad. It is experimental and 
has no proven effectiveness to benefit outcome. 
 
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 water circulating heat pad have not been met. Therefore, we decided that the 
Plan does not have to pay for the water circulating heat pad (E0217) provided from January 1, 2023, to January 
9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture (D9120). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
fixed partial denture (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressings 
(D7922). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
placement of intra-socket biological dressings (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered due to a previous 
provider breaking your tooth causing the core build-up to be necessary. The Plan denied your request. The Plan 
says this service is not a covered benefit under your dental 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 pre-approve a 
core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the refraction and the eye examination provided on 
March 29, 2023. 
 
You asked the Plan to pay more for the vision services. You say that you need regular exams and treatments 
that the out-of-network provider is the only one in your area that can provide the therapy. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by an out-of-network provider, up to $75. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $75 towards the vision services. Based on 
this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay more for the refraction and the eye examination 
provided on March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the CGM. You say that you are requesting a Dexcom G7 sensor to be 
provided to the enrollee. The Plan denied your request. The Plan says only the preferred brand products listed 
in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2393) for tooth #13 
provided by an out-of-network provider on May 8, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you did not know that your dentist was an 
out-of-network dentist and you had to have the filling done because of the pain you had. 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. 
 
  The total amount billed for the resin-based composite (D2393) was $362 and the total allowed amount was 
$124 leaving a difference of $238 ($362 billed - $124 allowed). 
 
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 resin-based composite (D2393) for tooth 
#13 provided by an out-of-network provider on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapies, of an anterior tooth (excluding final 
restoration) (D3310 x 5) provided from January 4, 2023, through January 23, 2023. 
 
You asked the Plan to pay for these 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 a covered benefit.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth.   
 
 
 
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does 
not have to pay for the endodontic therapies, of an anterior tooth (excluding final restoration) (D3310 x 5) 
provided from January 4, 2023, through January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the panoramic 
radiographic image (D0330) provided on April 14, 2023, and April 19, 2023. 
 You asked the Plan to pay for the dental services. You say that you were told that you would not have any 
responsibility and that it would be resolved. 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 the Plan paid for a limited oral evaluation (D0140) on March 28, 2023, and April 19, 2023; therefore, 
your benefit for the limited oral evaluation was exhausted on the date of service of April 19, 2023. The records 
also shows that the Plan paid for the intraoral complete series of radiographic images (D0210) on November 3, 
2021; therefore, your benefit for the panoramic radiographic image (D0330) was exhausted on the date of 
service of November 03, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and the panoramic radiographic image (D0330) provided on April 14, 2023, and April 19, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior (D2331) 
provided on May 16, 2023. 
 
You asked the Plan to pay for resin-based composite - two surfaces, anterior. You say that this is medically 
necessary. 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 resin-
based composite - two surfaces, anterior (D2331) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve maxillary partial denture (D5213) and mandibular partial denture (D5214). 
You say that you need your dentures to eat. You also say this benefit should be included in the Plan. The Plan 
denied your request. The Plan says these are not covered services of 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 pre-approve 
maxillary partial denture (D5213) and mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (A9270) provided on April 28, 
2023 and April 30, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
acupuncture services provided in this case.   
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and the Plans rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that the acupuncture 
services provided in this case were rendered by a licensed acupuncturist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture treatments (A9270) provided on April 28, 2023 and April 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D4263).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (A5500, A5513).  
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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.   
 
 
  Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (A5500, A5513).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustment of the complete mandibular denture (D5411) 
and  repair resin partial maxillary denture base (D5612) provided on March 31, 2023. 
 
You asked the Plan to pay for the adjustment of the complete mandibular denture (D5411) and repair resin 
partial maxillary denture base (D5612). You say that you were told by the Plan representative that as long as 
you used an in-network provider, the service you needed was covered. The Plan denied your request. The Plan 
says these services are not covered expenses under 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 
adjustment of the complete mandibular denture (D5411) and  repair resin partial maxillary denture base 
(D5612) provided on March 31, 2023.
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 you are appealing the denied foot orthotics. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2751) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought the procedure was covered under 
the plan for seniors. 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $96 for dental services on February 14, 2023. On March 6, 2023, the Plan paid $904 for 
dental services. For the year of 2023 the Plan paid $1,000 ($96 paid + $904 paid) for dental services; therefore, 
your benefit for the year of 2023 was exhausted on the date of service of March 6, 2023. Therefore, we decided 
that the Plan does not have to pay for a crown (D2751) provided on April 17, 2023.