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

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
on October 12, 2023. 
 
You asked the Plan to pay for the bitewings. You say that you were experiencing pain along your right gumline 
adjacent to a molar and it was determined that the bone adjacent to your molar had actually broken off.  You 
also say that in your opinion the D0274 bitewing should not have been denied in light of the problem you had 
with the bone fragment.  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 bitewings was exhausted on date of service January 24, 2023. Therefore, we decided 
that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided on October 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on July 
19, 2023. 
 
You asked the Plan to pay for a determination of refractive state. You say that you were never told this was not 
a routine eye examination, nor were you told there would be more copayments. The Plan denied your request. 
The Plan says this was not a preventive or routine service. 
 
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 the eye refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered during a 
routine eye examination. The record shows this was a medical or diagnostic eye examination. Based on this 
information, we decided that the Plan's rules for coverage of a determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pay for a determination of refractive state (92015) 
provided on July 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on September 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health visit. You say that there was no time to obtain a referral because 
a house call was necessary. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. Also, the services rendered were not urgent or emergent. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health visit provided on September 18, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) for the lower 
right quadrant provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that if the service is free, why do you have to pay 
anything. 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 24, 2023, and July 
28, 2023. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing 
(D4342) for the lower right quadrant provided on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty procedure. 
 
You asked the Plan to pre-approve the kyphoplasty procedure. You say that you have been in a lot of pain for 
two months and the medication and therapy does not help with the pain. The Plan denied your request. The 
Plan says kyphoplasty is 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 pre-approve the kyphoplasty procedure. Our 
reviewer says that kyphoplasty is not medically necessary. Our physician reviewer found that there is no 
documentation that the fracture is less than 12 weeks old and there is no trial of fracture bracing documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the kyphoplasty procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5226) provided on August 24, 
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 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 22, 2023. Therefore, 
we decided that the Plan does not have to pay for mandibular partial denture (D5226) provided on August 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary complete denture (D5110), mandibular 
partial denture (D5226) and unspecified adjunctive procedure (D9999 billed to represent lab fees) provided on 
June 29, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were overcharged for these services. 
The Plan denied your request. The Plan says one service is not a covered benefit under your dental plan, and 
the 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 50% 
coinsurance for these dental 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, D9999 billed to represent lab services  
is not among those covered under this benefit. 
 
You have been asked to pay $1,267.50 for the dental services. These items/services fall within the dental 
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 pay more for the maxillary complete denture 
(D5110), mandibular partial denture (D5226) and unspecified adjunctive procedure (D9999 billed to represent 
lab fees) provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the provider is in-network with the enrollee's 
plan. The Plan denied your request. The Plan says the provider in this case is not a network provider. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on August 22, 
2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on August 24, 2023, by an 
out-of-network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that you were not responsible to obtain 
authorization and the facility is responsible to obtain the authorization. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no approved authorization. Also, the services 
rendered were not urgent or emergent. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health visit provided on August 24, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive more of the coinsurance for mandibular partial denture 
(D5214) provided on July 13, 2023. 
 
You asked the Plan to waive more of the coinsurance for mandibular partial denture. You say that you think the 
Plan should pay the $343.75 because you have the optional coverage. 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 25% 
coinsurance for mandibular partial dentures.  
 
You have been asked to pay $343.75 in coinsurance, which is 25% of the allowed amount for mandibular 
partial denture ($1,375 x 25% = $343.75). This item/service falls within the optional supplemental dental 
package 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 more of the coinsurance for mandibular 
partial denture (D5214) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), and bone replacement graft for ridge preservation - per site (D7953) 
provided on June 5, 2023. 
 
You asked the Plan to pay for the extraction and bone replacement graft. You say that you had a dental abscess 
of a tooth that was extracted. The Plan denied your request. The Plan says services provided are not covered by 
Medicare. 
 
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 
your teeth or the structures directly supporting your 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 extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210), and bone replacement graft for ridge 
preservation - per site (D7953) provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), bifocal lenses (V2200), anti-reflective 
coating (V2750), polycarbonate lenses (V2784) and vision supplies or accessories (V2797) provided on August 
11, 2023. 
 
You asked the Plan to pay for frames, bifocal lenses, anti-reflective coating, polycarbonate lenses and vision 
supplies or accessories. You say that the person who rang you out for your visit and glasses made sure your 
insurance covered everything first. The Plan denied your request. The Plan says the benefit Plan does not cover 
out-of-network vision care services and materials. 
 
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 the eyeglasses are obtained through a Plan vision network 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from coverage. Based on this information, we decided that the Plan's rules for coverage 
of frames, bifocal lenses, anti-reflective coating, polycarbonate lenses and vision supplies or accessories have 
not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), bifocal lenses 
(V2200), anti-reflective coating (V2750), polycarbonate lenses (V2784) and vision supplies or accessories 
(V2797) provided on August 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 9, 2022, to May 8, 
2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
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 March 10, 2022. The NOA was not received by the Plan until November 
15, 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 
from April 9, 2022, to May 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
5, 2023. 
 
You asked the Plan to pay for the ED services. You say that you would like this claim to be reprocessed. The 
Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 5, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home visits for assistance with activities of daily 
living and personal care. 
 
You asked the Plan to pre-approve the home health visits. You say that you are in need of aide to assist with 
bathing for your medical conditions. The Plan denied your request. The Plan says the denial of authorization is 
correct, because the requested services are custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health visits have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the home 
visits for assistance with activities of daily living and personal care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination (92014) provided on August 7, 
2023.  
You asked the Plan to pay for a routine eye examination (92014). You say that you needed new glasses. You 
also say the provider checked your eyes and said you could use a new prescription. The Plan denied your 
request. The Plan says this service is not covered out-of-network. 
 
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 the routine eye examination is provided within the Plan's vision 
network. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations are not covered out-
of-network. Based on this information, we decided that the Plan's rules for coverage of a routine eye 
examination (92014) have not been met. Therefore, we decided that the Plan does not have to pay for a routine 
eye examination (92014) provided on August 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide services providing care in the 
home. 
 
You asked the Plan to pre-approve the home health aide services. You say that you need help to shower and the 
home health services are medically necessary. The Plan denied your request. The Plan says the denial of 
authorization is correct, because the the requested services is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
the home health aide services providing care in the home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic custom molded shoes. 
 
You asked the Plan to pre-approve the diabetic shoes. You say that you need your diabetic shoes as soon as 
possible. The Plan denied your request. The Plan says the denial of authorization is correct, because there is no 
signed order from your doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  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 diabetic shoes have been met. 
There is no valid physician order for the diabetic shoes. Therefore, we decided that the Plan does not have to 
pre-approve the diabetic custom molded shoes.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0428 and A0425 provided on July 13, 
2023. 
 
You asked the Plan to pay for procedure codes A0428 and A0425. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R06.89 has an Excludes1 note in relation to J96.90. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure codes A0428 and A0425 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes A0428 and A0425 provided on July 13, 2023.