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

 
We decided that the Plan does not have to waive the deductible for an in-network chest x-ray provided on June 
2, 2023. 
 
You asked the Plan to waive the deductible for an in-network chest x-ray. You say that everything was 
submitted and billed correctly, please reprocess. 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. Your 
contract with the Plan says that there is an in-network $400 deductible which applies to outpatient diagnostic 
tests and therapeutic services and supplies. You have been asked to pay $10.12 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is an in-network $400 deductible which applies to outpatient diagnostic 
tests and therapeutic services and supplies.  This cost sharing is a contractual obligation that had not been met at the time an in-network chest x-ray was 
received on June 2, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-
network chest x-ray provided on June 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (64628).

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of the pain is not clear.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220/D0230) provided on July 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were misled. 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 28, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral 
imaging (D0220/D0230) provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment applied for the hearing aid 
(V5257) purchased on April 13, 2023. 
 
You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a 
reconsideration of the Plan's denial for payment. 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 an $850 
copayment for an advanced plus level hearing aid.  
 
You have been asked to pay an $850 copayment for the advanced plus level hearing aid purchased in this case. 
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 issue reimbursement of the copayment applied for the hearing aid 
(V5257) purchased on April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction. 
 
You asked the Plan to pre-approve the breast reduction. You say that your provider says you would benefit 
from a breast reduction in order to improve your chronic back pain. You say you have tried physical therapy, 
dry needling, epidurals, trigger shots, massage, chiropractic treatments, and medication to reduce your back 
pain. The Plan denied your request. The Plan says the breast reduction is not medically necessary. The Plan 
says that your doctor is not planning to remove the medically necessary amount of breast tissue. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reduction. Our reviewer says 
that the service is not medically necessary. Our reviewer found the record indicates that you had breast 
hypertrophy. The record is insufficient to establish that the elements of the coverage rule are satisfied.  
 
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 breast reduction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the breast reduction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve applications of desensitizing resin for cervical root 
surfaces (D9911 x6) for, core buildups, including any pins when required (D2950 x3), crowns (D2740) for 
tooth #'s 6, 11, and 21, anterior resin-based composite for three surfaces (D2332), and posterior resin-based 
composites for two surfaces (D2392 x5). 
 
You asked the Plan to pre-approve the application of desensitizing resin, core buildups, crowns, and resin-
based composites. You say that you need to get fillings again because they fell out. You also say that you will 
get anything done that your insurance approves, but mainly the fillings, which you cannot keep waiting for. 
The Plan denied your request. The Plan says the application of desensitizing resin is not covered on your plan. 
The Plan also says that your core buildup, crown, and resin-based composite benefit limits have been met for 
the 2023 calendar year. 
 
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, application of desensitizing resin for 
cervical root surface (D9911) is not among those covered under this benefit. The contract clearly states that you 
are limited to 4 of (D2140-D2394) every calendar year. The record shows that your resin-based composite 
benefit was exhausted on February 23, 2023. The 2023 EOC says that you are limited to 3 of codes D2950 to 
D2954 every calendar year. The record shows you have been approved for 3 core buildups (D2950) as of 
October 10, 2023, and your core buildups benefit has been exhausted. 
 
The Plan contract also says that you are limited to 3 crowns (codes D2710 to D2792 and codes D6210 to 
D6792) every calendar year. The record shows that you received crowns (D2740) on tooth #s 6 and 11 on 
November 16, 2022, and your crowns benefit for tooth #s 6 and 11 have been exhausted. The documentation 
also shows that you were approved for 3 crowns (code D2740) for tooth #s 10, 19, and 28, hence, your crowns 
benefit for the 2023 calendar year has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve applications of desensitizing resin for cervical root surfaces (D9911 x6) for, core buildups, 
including any pins when required (D2950 x3), crowns (D2740) for tooth #'s 6, 11, and 21, anterior resin-based 
composite for three surfaces (D2332), and posterior resin-based composites for two surfaces (D2392 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a crown (D2752) for tooth #5 and #6, the 
core buildup (D2950) for tooth #5 and #6, and to pay for the application of medicament (D9910) provided on 
July 20, 2023. 
 
You asked the Plan to waive the copayments for the dental services. You say that the provider is charging you 
incorrectly. The Plan denied your request. The Plan says this cost sharing was charged correctly. Also, the 
application of medicament is not covered by the Plan. 
 
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 $440 
copayment for a crown (D2752) and a $95 copayment for the core buildup (D2950). The total copayment 
amount for both crowns (D2752) was $880 ($440 copayment x 2 crowns). The total copayment amount for 
both core buildups (D2950) was $190 ($95 copayment x 2 core buildups). 
 
You have been asked to pay a $1,070 copayment for the dental services. This item/service falls within the 
patient charge schedule 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. The application of medicament is not covered under the Plans dental benefit. Therefore, 
we decided that the Plan does not have to waive the copayments for a crown (D2752) for tooth #5 and #6, the 
core buildup (D2950) for tooth #5 and #6, and to pay for the application of medicament (D9910) provided on 
July 20, 2023.  
 
Your complaint about the provider billing for dental services 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 immediate mandibular/maxillary dentures, extractions, 
alveoloplasty in conjunction with extractions, and drugs or medicaments dispensed in the office for home use 
(D5140, D5130, D7140, D7210, D7310, D9630) provided on May 24, 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 the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Additionally, this benefit does not include 
drugs or medicaments dispensed in the office for home use. 
 
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. Additionally, this benefit does not include drugs or 
medicaments dispensed in the office for home use, regardless of the providers network status. Therefore, we 
decided that the Plan does not have to pay for immediate mandibular/maxillary dentures, extractions, 
alveoloplasty in conjunction with extractions, and drugs or medicaments dispensed in the office for home use 
(D5140, D5130, D7140, D7210, D7310, D9630) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
April 15, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on April 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 30, 2023, to April 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to this dental office because they are 
familiar with your needs. 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 by an out-of-network provider on March 30, 2023, to April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2520) provided on August 11, 2023. 
 You asked the Plan to pay for contact lenses (V2520). 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 up to a $150 allowance every calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan will provide reimbursement for up to 
a $150 allowance every calendar year. The record shows that the Plan reimbursed $75 for date of service May 
13, 2023. The record also shows that the Plan reimbursed another $75 for date of service August 11, 2023, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of contact 
lenses (V2520) have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses 
(V2520) provided on August 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical care needs. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 30, 2022, to 
September 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 30, 2022, to 
September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 7, 
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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5130) purchased on April 18, 2023. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not payable as it was purchased from an 
out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aid in this case was 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5130) purchased on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 6, 2023, billed with 
codes 81225, 81226, 81227, 81328, 81240, and 81241. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 6, 2023, billed with codes 81225, 81226, 81227, 81328, 81240, and 81241.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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.