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

 
We decided that the Plan does not have to pay more for limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220) and bitewings (D0270) provided on January 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220) and bitewings (D0270) provided on January 3, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture  mandibular (D5140) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) x7 provided on March 7, 2023, and March 14, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not understand why the services are not 
covered. The Plan denied your request. The Plan says the services are not covered under your 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. Immediate denture  
mandibular (D5140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and 
including elevation of mucoperiosteal flap if indicated (D7210) are not covered under your Plans dental 
services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5140 and D7210 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
immediate denture  mandibular (D5140) and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x7 provided on March 
7, 2023, and March 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided from March 20, 2023, to 
March 29, 2023. 
 
You asked the Plan to pay for a self-administered drug. You say that you feel the self-administered drugs 
received while you were admitted in the hospital should be paid. 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 a self-administered drug 
provided from March 20, 2023, to March 29, 2023.  
 
Benefits for a self-administered drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80050 provided on May 2, 2022. 
 
You asked the Plan to pay for procedure code 80050. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for procedure code 80050 
provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral- periapical first 
radiographic image (D0220) provided on February 20, 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 benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral- periapical first radiographic image (D0220) 
provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the 
comprehensive series of radiographic images (D0210), the diagnostic casts (D0470), and a cleaning (D1110) 
provided by an out-of-network provider on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that no one told you that the dentist was out-of-
network when the service was rendered. 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 a comprehensive oral evaluation (D0150), the comprehensive series of radiographic images (D0210), 
the diagnostic casts (D0470), and a cleaning (D1110) provided by an out-of-network provider on January 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic service. 
 
You asked the Plan to pay for chiropractic service. You say that it is medically necessary. The Plan denied your 
request. The Plan says they cover only manual manipulation of the spine to correct subluxation. 
 
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 chiropractic service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on January 9, 2023, by an out-
of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware using an out-of-
network provider would cost this much. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for dental services provided on January 9, 2023, 
by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thoracoscopic left atrial appendage occlusion (LAAO) 
(33269). 
 
You asked the Plan to pre-approve thoracoscopic LAAO. 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 thoracoscopic LAAO. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the safety and efficacy of stand-alone, thoracoscopic left atrial appendage occlusion. As such, guidelines would not support thoracoscopic LAAO in this setting. In summary, 
thoracoscopic LAAO would not be considered reasonable or medically necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thoracoscopic LAAO have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thoracoscopic left atrial appendage occlusion (LAAO) (33269).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic and retainer crown (D6750, D6240) provided on 
January 12, 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 pontic 
and retainer crown (D6750, D6240) provided on January 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 24, 2023, to 
March 31, 2023. 
 
You asked the Plan to pay for skilled nursing services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing services 
provided on February 24, 2023, to March 31, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2023, 
to January 19, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you believe the facility kept you 
admitted just to receive the copayment and not because you required the services. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $1,764 for a SNF stay ($196 per day x 9 days = $1,764). This item/service falls 
within the SNF 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 a SNF stay provided 
from January 1, 2023, to January 19, 2023.  
 
Your complaint about the facility keeping you longer than you feel was necessary 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 intraoral and bitewing x-rays, application of caries arresting 
medicament, and periodontal maintenance services (D0220, D0230, D4910, D0274, D1354) provided on 
December 21, 2022. 
 
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 intraoral 
and bitewing x-rays, application of caries arresting medicament, and periodontal maintenance services (D0220, 
D0230, D4910, D0274, D1354) provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. 
 You asked the Plan to pre-approve the compression stockings. You say that these services should be considered 
due to the enrollee's past medical history. The Plan denied your request. The Plan says there is no 
documentation of wounds due to surgical debridement or other surgical intervention. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code E1399.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 31, 2022, billed 
with code 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 part of 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 December 31, 2022, billed with code 81292.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam provided on 
January 09, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that you were sent to see a 
different provider and should not have to pay for this. 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 $35 
copayment for vision care, including diagnostic eye exams. 
 
You have been asked to pay a $35 copayment for the diagnostic eye exam. This item/service falls within the 
vision care, including diagnostic eye exams 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 diagnostic eye exam provided on January 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the 
comprehensive series of radiographic images (D0210) provided by on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was the providers decision to do x-rays again 
and another evaluation. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 that the Plan paid for a comprehensive oral evaluation and the comprehensive series of radiographic 
images on May 25, 2021; therefore, your benefit for the requested items or services was exhausted on the date 
of service of May 25, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and the comprehensive series of radiographic images (D0210) provided by on February 16, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure and retainer crown (D6750, 
D4240) provided on January 19, 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 gingival 
flap procedure and retainer crown (D6750, D4240) provided on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the MRI on February 28, 2023. 
 
You asked the Plan to waive the cost share for the MRI. You say that you should not have to pay for test you 
do not think you needed. 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 a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. 
 
The item or service you asked the Plan to waive the cost share 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 a $750 deductible which applies to the MRI. This cost sharing is a 
contractual obligation that had not been met at the time the MRI was received on February 28, 2023. Therefore, 
we decided that the Plan does not have to waive the cost share for the MRI on February 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 01, 2022, to 
December 17, 2022. 
 
You asked the Plan to pay for skilled nursing services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing services 
provided on December 01, 2022, to December 17, 2022.