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

 
We decided that the Plan does not have to pay more for dental services provided on February 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered.  The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for dental services provided on February 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), a cone 
beam (D0367), a complete upper denture (D5110), and implant supported abutment (D6111) provided on 
November 3, 2022, and November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you made multiple calls and were told you are 
covered for implants and dentures. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the comprehensive periodontal evaluation, a cone beam, a complete upper denture, 
and implant supported abutment are not covered by the Plan. Also, it was verified that no phone calls were ever 
made to the Plan prior to the dates of 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 pay for the 
comprehensive periodontal evaluation (D0180), a cone beam (D0367), a complete upper denture (D5110), and 
implant supported abutment (D6111) provided on November 3, 2022, and November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with codes A4206, A4208, and A4649, 
codes 83735 and J1956, and testing services billed with codes 96361, 96367, 96374 and 96375 for September 
15, 2022. 
 
You asked the Plan to pay for procedure code A4206 and A4208. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4206 and A4208 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4206 and A4208 are statutorily excluded. We find that procedure code 
A4649 has a Status Indicator of P on the Physician Fee Schedule. This means that procedure code A4649 is a 
bundled/excluded code. Based on this information, we decided that Medicare rules for coverage of procedure 
code A4206, A4208, and A4649 have not been met. 
 
The rules say that payment for codes with a PC/TC indicator of 5 may not be made when performed in the 
hospital inpatient setting. 
 
We find that procedure codes 96361, 96367, 96374 and 96375 have a PC/TC indicator of 5 and were 
performed in the inpatient hospital setting. These codes are therefore not separately payable. 
 
The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. 
 
The file includes evidence that procedure codes 83735 and J1956 were reimbursed by the Plan on a prior claim. 
Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that 
the billed items/services were provided twice on the same date. Based on this information, we decided that the 
Medicare rules for these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the supplies billed with codes A4206, A4208, and 
A4649, codes 83735 and J1956, and testing services billed with codes 96361, 96367, 96374 and 96375 for 
September 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 94640 billed for date of service January 8, 
2023. 
 
You asked the Plan to pay for codes 93005 and 94640. You say that these emergency services are coverable and should be paid. The Plan denied your request. The Plan says these codes are not separately payable.
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning they are STV-packaged services.  These disputed codes were billed on the same claim with a code that 
has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005 and 94640 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 93005 and 94640 billed for date of service January 8, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 63045 and 63048 rendered on February 28, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 63045: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical 
 
CPT 63048: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that in terms of CPT 63045, the procedure 
details cite a bilateral C3 laminectomy and partial medial facetectomy was performed with resection of the 
ligamentum flavum and caudal bone at C3. This was performed outside of the operative area of the C4-6 
laminoplasty procedure. Therefore, the records do support CPT 63045 as a separate and distinct procedure from 
CPT 63051.  
 
In terms of CPT 63048, the procedure details cite a bilateral C7 laminectomy and partial medial facetectomy 
was performed with resection of the ligamentum flavum and cephalad bone at C7. Therefore, the records do 
support CPT 63048 in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 63045 and 63048 rendered on February 28, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a filling (D2391) provided on February 
14, 2023. 
 
You asked the Plan to waive the coinsurance 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 the cost-sharing applied 
correctly based on the services provided. 
 
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 
subject to coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for a filling 
(D2391) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on October 03, 2022. 
 
You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration for the services 
provided. 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 outpatient visit provided 
on October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery procedures provided on January 31, 2023. 
 
You asked the Plan to pay for oral surgery procedures. 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 oral 
surgery procedures provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete maxillary denture (D5730) provided on 
January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial untimely because 
you were not aware that you had dental coverage. 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 pay for the reline 
complete maxillary denture (D5730) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on Feb 08, 
2023. 
 
You asked the Plan to pay for the dental services. You say that there was no way for you to know that the 
providers network status lapsed prior to your appointment. 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 the periodontal maintenance (D4910) provided on Feb 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture provided on Jan 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider told you that the Plan would pay 
for 50% of the partial denture. 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 pay for the 
maxillary partial denture provided on Jan 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on December 21, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that the compression garments are medically 
necessary for your medical problems. The Plan denied your request. The Plan says the items are not covered by 
Medicare or the Plan. 
 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 pay for the compression 
stockings identified with code A6549 that were issued on December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 30, 2022, to July 29, 
2022. 
 You asked the Plan to pay for home health services. You say that the medical records support medical 
necessity. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 30, 2022, to July 29, 2022. The NOA was not received by the Plan 
until October 28, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided on June 30, 2022, to July 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, Q5002) provided on 
October 25, 2022, to November 23, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 25, 2022. The NOA was not received by the Plan until November 
29, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0152, Q5002) provided on October 25, 2022, to November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 25, 2023, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you thought that the provider was in-network. 
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 January 25, 2023, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 30, 2023. 
 You asked the Plan to pay for the home visit. You say that the service was not hospice related. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a home visit provided on January 30, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing care provided on April 14, 2022. 
 
You asked the Plan to pay for the nursing care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing care provided on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was given a diagnosis of a 
mild cognitive impairment (MCI). The enrollee was not noted to have either AD or FTD, let alone both. The 
base requirement of the NCD for coverage of the requested service has not been met. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physician office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a physician office visit. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a physician office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on January 17, 2023.