Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty provided on July 28, 2023. 
 
You asked the Plan to pay for the arthroplasty. You say that the out-of-network provider was the only available 
assistant at the time of the procedure and rendered the services specifically requested by the in-network 
primary physician and in-network facility. The Plan denied your request. The Plan says the provider is 
credentialed as a Registered Nurse First Assistant and is non-participating with the network. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty provided on July 28, 
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 need orthopedic shoes and special insoles 
because of your rheumatoid arthritis. 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 reline complete mandibular denture (D5751) provided on 
August 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the two procedures should have been billed as 
one, since the first procedure is necessary before the second one is done. 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 17, 2023. Therefore, 
we decided that the Plan does not have to pay for reline complete mandibular denture (D5751) provided on 
August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), and bitewings - four radiographic images (D0274) provided on August 2, 2023. We also decided that 
the Plan does not have to pay for the prophylaxis  adult (D1110) provided on August 2, 2023. 
 
You asked the Plan to pay more for the periodic oral evaluation and bitewings. You also asked the Plan to pay 
for the prophylaxis - adult .You say that the handbook states that for out-of-network services the plan pays 
50%, but you only received $21.00 when you should have received $160.00. 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. The Plan also says your benefit for the prophylaxis - 
adult 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. 
 
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 the periodic oral evaluation - established 
patient (D0120), and bitewings - four radiographic images (D0274) provided on August 2, 2023.   
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the prophylaxis - adult was exhausted on date of service January 24, 2023. Therefore, 
we decided that the Plan does not have to pay for the prophylaxis - adult provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new/established patient 
(D0150), intraoral  periapical first radiographic image (D0220) and intraoral  periapical, each additional 
radiographic image (D0230) provided on July 13, 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 comprehensive oral evaluation 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 comprehensive oral evaluation was exhausted on date of service January 23, 2023. Intraoral  periapical first radiographic image and intraoral  periapical, each additional radiographic image are 
not covered services. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation  new/established patient (D0150), intraoral  periapical first radiographic image (D0220) and 
intraoral  periapical, each additional radiographic image (D0230) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames, lens, and warranty purchased on September 
11, 2023. 
 
You asked the Plan to pay more for the frames, lens, and warranty. You say that your glasses broke, and you 
needed them immediately. The Plan denied your request. The Plan says the warranty purchased is non-covered. 
The Plan also says that your cost share is correct at $69.87. 
 
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 up to a $100 allowance for non-Medicare covered eyewear, and 20% off the balance 
over $100 for frames, lens, and lens option package.  
We looked at the file and the Plan's rules. The record shows that you received $100 for the frames/lens 
allowance, and you received 20% discount for remaining frame/lens amount due after $100 allowance was 
applied. Warranties are not covered under the Plan. Based on this information, we decided that the Plan's rules 
for coverage of the frames, lens, and warranty have not been met. Therefore, we decided that the Plan does not 
have to pay more for the frames, lens, and warranty purchased on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral first x-ray (D0220) and a limited oral evaluation 
(D0140) provided on August 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you saw the dentist after your front tooth 
chipped. You also say you were seeking consultation on next steps, so 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 April 10, 2023. Therefore, we decided that the Plan does not have to pay for intraoral first x-ray (D0220) and a limited oral 
evaluation (D0140) provided on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that his was the same 
procedure. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 9, 2023. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 23, 
2023. 
 
You asked the Plan to pay for the dental services. You say that obviously the procedure that was performed on 
August 23, 2023, by your dentist was not just periodontal maintenance. You also say it was a comprehensive 
dental procedure to save your teeth and gum, as much as possible. 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 April 20, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473), deep 
sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 
minute increment (D9223) provided on July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that your health and dental plans state this service is 
a medical procedure. You also say that this procedure was done because the tori was growing and became very 
painful and hard to eat. The Plan denied your request. The Plan says D7473 is not a covered benefit under your 
plan, D9222, and D9223 is only covered when performing a covered dental 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 the 
removal of torus mandibularis (D7473), deep sedation/general anesthesia  first 15 minutes (D9222), deep 
sedation/general anesthesia  each subsequent 15 minute increment (D9223) provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 27, 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 $1,000 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia-first 15 minutes (D9222) 
provided on July 28, 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 $1,500 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay for deep sedation/general anesthesia-first 15 minutes (D9222) provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service August 17, 
2023. 
 You asked the Plan to pay for procedure code 99204. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99204 is bundled into payment for code 
93016. 
 
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 99204 
is a column II code to column I code 93016. 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 99204 billed for date of service August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on May 3, 
2022, to June 1, 2022. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you have tried multiple 
times to reach out to start a claim. The Plan denied your request. The Plan says that the claim was not filed 
timely. 
 
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 the chiropractic manipulative treatment was not filed until June 14, 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 chiropractic manipulative treatment provided 
on May 3, 2022, to June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says D9944 is 
not listed as a covered 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal 
guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 You asked the Plan to pre-approve the additional trips. You say that you need the additional non-emergent 
transportation trips as you are on dialysis and need a ride three times a week. The Plan denied your request. 
The Plan says the records shows that as of October 17, 2023 you have used or scheduled 100 one-way trips. 
Your 100 trips may include some trips that you have already scheduled but have not used. 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation trips for your dialysis appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on August 25, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. 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 and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950), and application of desensitizing resin for cervical and/or root 
surface, per tooth (D9911). 
 
You asked the Plan to pay for the dental services. You say that you were having extreme pain in your mouth 
due to not having your crown and this is only a general service. You also say that if the service is not covered 
you will be leaving the plan. The Plan denied your request. The Plan says as you have supplemental dental 
benefits the health plans benefit chart should be used in determining coverage. D2740, D2950, and D9911 are 
not listed as covered 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), and application of 
desensitizing resin for cervical and/or root surface, per tooth (D9911).  
 
Your complaint about leaving the plan if the services are not covered is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for soft liner for complete or partial removable denture  indirect 
(D5765) provided on July 14, 2023. 
 
You asked the Plan to pay for soft liner for complete or partial removable denture  indirect. 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 soft liner 
for complete or partial removable denture  indirect (D5765) provided on July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need these compression 
stockings. The Plan denied your request. The Plan says the requested stockings have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve D9945. You say that you would like the Plan to approve this. The Plan 
denied your request. The Plan says the requested dental service is not a covered 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 pre-approve an 
occlusal guard (D9945).