Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay on April 15, 
2023, to April 21, 2023.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel 
responsible because you were never officially discharged from the hospital due to medical complications. 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 $225 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for the inpatient hospital stay. However, the copayment 
on this claim caused you to meet your annual maximum out-of-pocket cost so, you are being assessed a lesser 
amount of $950. You have not been charged for the day you were discharged. This item/service falls within the 
inpatient hospital care 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 the copayment for the inpatient 
hospital stay on April 15, 2023, to April 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parotidectomy and inpatient services provided on May 
31, 2023, to June 3, 2023, by an OON provider.  
 
You asked the Plan to pay for the parotidectomy and inpatient services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the service was not authorized. 
 
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 parotidectomy and inpatient services provided 
on May 31, 2023, to June 3, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99213 for date of service May 15, 2023, to June 19, 2023.

You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that many of these "XXX" global period procedures are performed by physicians and have inherent pre-procedure, intraprocedure, and post-procedure work usually performed each time the procedure is completed. This work shall not be reported as a separate E&M code.

We looked at the file and Medicare rules. Review of the file shows that code 97605 was also billed on the same date of service. Code 97605 has a global period of XXX. Code 99213 was billed with modifier -25. The documentation does not show that a significant and separately identifiable E&M service that is above and beyond the usual pre and post operative work of the procedure on the same date of service. Based on this information, we decided that Medicare rules for coverage of procedure code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 for date of service May 15, 2023, to June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), 
polycarbonate lenses (V2784), single vision lenses (V2104, V2105) and vision items or services (V2799) 
provided on June 10, 2023. 
 
You asked the Plan to pay for frames (V2020), anti-reflective coating (V2750), polycarbonate lenses (V2784), 
single vision lenses (V2104, V2105) and vision items or services (V2799). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses (1 per 
calendar year). The Plan contract also says that you are responsible for any amount over $300 retail price. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $300 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses (1 per calendar year). The Plan rules also say that you are 
responsible for any amount over $300 retail price. The record shows this benefit was exhausted. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), anti-reflective coating (V2750), 
polycarbonate lenses (V2784), single vision lenses (V2104, V2105) and vision items or services (V2799) have 
not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), anti-reflective 
coating (V2750), polycarbonate lenses (V2784), single vision lenses (V2104, V2105) and vision items or 
services (V2799) provided on June 10, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's current condition does not require daily skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on April 21, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you were not aware that this provider 
was not in the healthcare network. You also say you were told earlier that they were. The Plan denied your 
request. The Plan says the provider is not part of the vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you obtain the hearing aids through a Plan hearing network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatologist visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a dermatologist visit. You say that the services are medically necessary. The 
Plan denied your request. The Plan says this is available in-network. 
 
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 dermatologist 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 more for dental services provided by an out-of-network provider 
on June 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe 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 by an out-of-
network provider on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on June 15, 2023. 
 
You asked the Plan to pay for D4346. You say that you verified coverage for this. The Plan denied your 
request. The Plan says the denied 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 pay for scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided on April 21, 2023.  
 
You asked the Plan to pay for hearing aids (V5298). You say that you do not understand why the provider 
performed the services if you were not covered for them. The Plan denied your request. The Plan says these 
services are not covered under your medical benefit. The Plan also says they do offer supplemental hearing aid 
coverage, but you did not purchase this supplemental benefit Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the supplemental benefit for hearing aids have been purchased.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5298) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 9, 2023. 
 
You asked the Plan to pay for the office visit. You say that you thought you only had to pay a $20 copayment. 
The Plan denied your request. The Plan says the service was not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) for tooth #20, #21, #22, #23, #24, #25, 
#26, #27, and #28, the alveoloplasty (D7310), the sedation (D9243), and a consultation (D9310) provided on 
April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were quoted a price and now the Plan will 
not pay for the dental services. 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 $94 for dental services on March 20, 2023. On April 17, 2023, the Plan paid $1,406 for 
dental services. For the year of 2023 the Plan paid $1,500 ($94 paid + $1,406 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
April 17, 2023. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) for tooth 
#20, #21, #22, #23, #24, #25, #26, #27, and #28, the alveoloplasty (D7310), the sedation (D9243), and a 
consultation (D9310) provided on April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on June 11, 2023, to June 
14, 2023. 
 
You asked the Plan to pay for the medication. You say that the medications that you took were all prescribed 
by the doctor. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on June 11, 2023, to June 14, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 7, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) for tooth #22 and 
#27, the surgical placement of implant body (D6010) for tooth #22 and #27, the surgical removal of erupted 
tooth (D7210) for tooth #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27, the bone replacement graft 
(D7953) for tooth #22 and #27, and the parenteral drug (D9610) provided on October 8, 2022. You asked the Plan to pay for the dental services. You say that you had your lower teeth removed for dentures 
using your benefits. The Plan denied your request. The Plan says your benefit for the surgical removal of 
erupted tooth has already been exhausted. Also, the guided tissue regeneration, the surgical placement of 
implant body, the bone replacement graft, and the parenteral drug are not covered by 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, certain limitations apply. The record 
shows the Plan paid for the surgical removal of erupted tooth (D7210) for tooth #28 and #31 on October 8, 
2022; therefore, your benefit for the surgical removal of erupted tooth was exhausted on the date of service of 
October 8, 2022. The guided tissue regeneration, the surgical placement of implant body, the bone replacement 
graft, and the parenteral drug are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for the guided tissue regeneration (D4266) for tooth #22 and #27, the surgical 
placement of implant body (D6010) for tooth #22 and #27, the surgical removal of erupted tooth (D7210) for 
tooth #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27, the bone replacement graft (D7953) for tooth #22 
and #27, and the parenteral drug (D9610) provided on October 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided on June 13, 
2023. 
 
You asked the Plan to pay for D9310. You say that this was for a second opinion. The Plan denied your 
request. The Plan says the rendered 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 pay for a 
diagnostic consultation (D9310) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy and acupuncture services provided on July 
25, 2023. 
 
You asked the Plan to pay for  infrared therapy and acupuncture services. You say that you were diagnosed 
with cervical spondylosis without myelopathy in your neck. The Plan denied your request. The Plan says that 
the only covered acupuncture service is for chronic low back pain. 
 
  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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the only covered acupuncture service is for chronic 
low back pain, and anything not associated is not covered. Therefore, we decided that the Plan does not have to 
pay for  infrared therapy and acupuncture services provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), and mandibular partial denture - flexible base (including any clasps, rests and 
teeth) (D5226) provided on March 22, 2023, and April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dental benefits had 
been assigned to the dental plan provider until you received the denial letters. You also say that they you did 
not receive your Evidence of Coverage (paper copy by mail) until May 26, 2023, you were not provided a 
directory of dental in-network providers, and you do not own a computer or have any knowledge of computers. 
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 extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and 
mandibular partial denture - flexible base (including any clasps, rests and teeth) (D5226) provided on March 
22, 2023, and April 4, 2023.