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

 
We decided that the Plan does not have to pay for a deep sedation/general anesthesia (D9222, D9223) provided 
on December 14, 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 a deep 
sedation/general anesthesia (D9222, D9223) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays, nutritional counseling for control of dental 
disease, and oral hygiene instructions (D0230, D1310, D1330) provided on February 17, 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 intraoral x-rays has already 
been exhausted. Coverage for the nutritional counseling for control of dental disease and oral hygiene 
instructions 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2023. 
Therefore, we decided that the Plan does not have to pay for the additional x-rays, nutritional counseling for 
control of dental disease, or oral hygiene instructions (D0230, D1310, D1330) provided on February 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 20, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are in 
a nursing home and the paramedics checked your vitals and found you to be in good health. You also say that 
you declined the transportation. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), the 
pontics (D6245), and the retainer crowns (D6740) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should honor the pre-determination and 
pay for the dental services. The Plan denied your request. The Plan says your dental allowance 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 on May 5, 2022, the Plan paid $229 for dental services. On June 30, 2022, the Plan paid $23 for dental 
services. On August 1, 2022, which the claim was received prior to the claim for July 7, 2022, the Plan paid 
$259 for dental services. On August 26, 2022, which the claim was received prior to the claim for July 7, 2022, 
the Plan paid $2,239 for dental services. For the year of 2022 the Plan paid $2,750 ($229 paid + $23 paid + 
$259 paid + $2,239 paid) for dental services. Therefore, your dental benefit allowance for the year was 
exhausted prior to when the claim for July 7, 2022, was received. Therefore, we decided that the Plan does not 
have to pay for the intraoral radiographic images (D0220 and D0230), the pontics (D6245), and the retainer 
crowns (D6740) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel the evaluation should be covered 
because it is a procedure that is covered every 6 months. 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 the date of service of April 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee should not be liable for the 
received services. 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. This benefit includes the 
requested item or service but is limited to you pay 100% of charges beyond the $2,000 annual allowance or if 
you exceed a service limit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $49 for services on April 14, 2022, $512 for services on May 2, 2022, $204 for services on 
May 3, 2022, and $1,235 for services on July 6, 2022 (49 + $512 + $204 + $1,235 = $2,000). After the annual 
maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan 
does not have to pay more for dental services provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should honor the pre-determination and 
pay for the dental services. The Plan denied your request. The Plan says your dental allowance 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 on May 5, 2022, the Plan paid $229 for dental services. On June 30, 2022, the Plan paid $23 for dental 
services. On August 1, 2022, the Plan paid $259 for dental services. On August 26, 2022, the Plan paid $2,239 
for dental services. For the year of 2022 the Plan paid $2,750 ($229 paid + $23 paid + $259 paid + $2,239 paid) 
for dental services; therefore, your dental benefit allowance for the year of 2022 was exhausted on the date of 
service of August 26, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation (D0120) and a cleaning (D1110) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 January 23, 2023. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on January 
23, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on February 3, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says that the services were already paid for. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for dental services provided on 
February 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) 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 core 
buildup services (D2950) provided on January 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy with transoral incisionless 
fundoplication (TIF) rendered on November 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service does not meet the requirements for the plan and is excluded from coverage. 
 
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case there is no provided documentation of post-Nissen PPI-refractory advanced esophagitis, 
of lack of response nor intolerance to acid suppression therapy, of symptoms correlative with acid reflux 
events, nor was manometry data presented to objectively show that the enrollee's lower esophageal sphincter 
presently requires re-augmentation by surgical re-intervention. As such, the medical necessity of the TIF 
procedure is not apparent based on Appellants available records, especially given the substantial complication 
and failure rates of the transoral incisionless fundoplication (TIF) procedure and absence of contemporary 
medical literature to demonstrate the superiority of TIF versus gold-standard laparoscopic Nissen 
fundoplication. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for esophagogastroduodenoscopy with transoral incisionless fundoplication (TIF) rendered on 
November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x 4). 
 
You asked the Plan to pay for the dental services. You say that your provider told you that these services are 
covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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, 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 2D 
oral/facial photographic images (D0350 x 4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D imaging and reporting (76377).

You asked the Plan to pre-approve 3D imaging and reporting. You say that a 3D rendering is medically necessary. The Plan denied your request. The Plan says the provided documentation does not support why a 3D rendering is necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 3D imaging and reporting. Our reviewer says that the requested 3D imaging and reporting is not considered medically reasonable and necessary in this case. Our physician reviewer found the approved CT of the shoulder will automatically include axial and reconstructed coronal and sagittal images. The reviewer found there is no valid indication for a 3D rendering which will include special imaging manipulation and viewing on a separate workstation. The reviewer found that such rendering is reserved only when there is limitation based upon the acquired standard imaging. The reviewer found that no such limitation is described in the submitted request for 3D rendering. Therefore, the reviewer found that a 3D rendering is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D imaging and reporting have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D imaging and reporting (76377).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code G0453. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code G0453 is bundled into payment for code 
95829. 
 
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 G0453 
is a column II code to column I code 95829. 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 G0453 billed for date of service December 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has paid the full $2,000 dental benefit for services provided on January 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee should not be liable for the 
received services. 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. This benefit includes the 
requested item or service but is limited to you pay 100% of charges beyond the $2,000 annual allowance or if 
you exceed a services limit. 
 
  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 January 11, 2023. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on January 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), comprehensive periodontal evaluation - new or established patient (D0180), gingival 
irrigation  per quadrant (D4921) provided on December 2, 2022, and December 16, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0350, D0180, and D4921. You say 
that you only wanted a deep cleaning and gave your card to the dentist office and assumed the services would 
be covered. You also say that you want the Plan to resolve this with the dentist's office and pay for the claim. 
The Plan denied your request. The Plan says these services are not covered under your plan and no payment 
can be made. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350), comprehensive periodontal 
evaluation - new or established patient (D0180), gingival irrigation  per quadrant (D4921) provided on 
December 2, 2022, and December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth number 9 provided on 
November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is the result of your provider ignoring your 
concerns about the tooth. 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 12, 2019. Therefore, 
we decided that the Plan does not have to pay for the crown (D2740) for tooth number 9 provided on 
November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on May 30, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on May 30, 2022. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 99223 provided on May 30, 2022. 
 
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, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on May 30, 2022. Our reviewer found code 99223 
was not supported in the medical record. There was no documentation of a comprehensive history. The review 
has determined that the medical records did not support the billing of code 99223 provided on May 30, 2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on May 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3031). 
 
You asked the Plan to pre-approve the foot orthotics. You say that you don't understand why orthotics for 
osteoarthritis are not covered. You also say that they are trying this as a first step to avoid having to replace the 
joint with surgery. 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 (L3031).