Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on February 18, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99285.  
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 99285. Our reviewer says that the medical 
records do not support the billing of code 99285. Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a high level. 
 
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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on February 18, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 6, 2022, to 
September 4, 2022.  
 You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
 
The enrollee ended Medicare Hospice benefits on August 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the home health 
services provided on August 6, 2022, to September 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services requested are medically necessary. 
The Plan denied your request. The Plan says  the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88271 and 88275 billed for date of service 
May 12, 2022. 
 You asked the Plan to pay for procedure codes 88271 and 88275. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 88271 and 88275 is bundled into 
payment for code 81261. 
 
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 codes 
88271 and 88275 are column II codes to column I code 81261. 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 codes 88271 and 88275 billed for 
date of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and manipulative treatment provided by a 
chiropractor on April 7, 2023. 
 
You asked the Plan to pay for office visit and manipulative treatment provided by a chiropractor. You say that 
if you had known there was going to be an added fee, you would not have had the services rendered. The Plan 
denied your request. The Plan says this is not a covered chiropractic service. 
 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 office visit 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 by a chiropractor on April 7, 2023. 
 
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 $500 deductible which applies to Chiropractic services. 
 
The manipulative treatment you asked the Plan to pay for falls within the Chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time manipulative treatment was received on April 7, 2023. Therefore, we decided that the Plan does 
not have to pay for manipulative treatment provided by a chiropractor on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on March 21, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused and intraoral - periapical first 
radiographic image. You say that services D0140 and D0229 should be covered under your dental plan. The 
Plan denied your request. The Plan says these 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. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) provided on 
March 21, 2023.  
 
Your complaint about your experience with the providers staff 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 a porcelain/ceramic crown (D2740) provided on February 
22,2023. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740). You say that your Plan clearly indicates that 
dental restorative services are covered at 50%. You also say that dental restoration within the dental community 
covers fillings, onlays, and crowns to restore the original shape of the tooth in question. The Plan denied your 
request. The Plan says this is not a covered expense. 
 
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 
porcelain/ceramic crown (D2740) provided on February 22,2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99213) provided on March 20, 2023. 
 
You asked the Plan to pay for a specialist office visit (99213). You say that you had an infection that had 
already gone to your ear and throat. You also say that you could not wait until your dentist had an opening, so 
you called your clinic for an appointment to get an antibiotic. The Plan denied your request. The Plan says this 
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 
specialist office visit (99213) provided on March 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 3, 2022, to July 
2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. 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 June 3, 2022, to July 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic for tooth #29 and #30 (D2740) 
provided on March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the 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. Therefore, we decided that the Plan does 
not have to pay for crown - porcelain/ceramic for tooth #29 and #30 (D2740) provided on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), 2D oral imaging (D0350), a 
resin-based composite (D2331), and periodontal scaling and root planing (D4341), provided March 2, 2023, to 
March 6, 2023. 
 
You asked the Plan to pay for D4921, D0350, D2331, and D4341. You say that you feel like these services 
should be covered. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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, D4921 and D0350 are not among those 
covered under this benefit. A 50% coinsurance has been applied to D2331 and D4341. Therefore, we decided 
that the Plan does not have to pay for gingival irrigation (D4921), 2D oral imaging (D0350), or pay more for a resin-based composite (D2331), and periodontal scaling and root planing (D4341), provided March 2, 2023, to 
March 6, 2023.
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), provided on April 28, 2023. 
 
You asked the Plan to pay for D0140 and D0220. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 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), and intraoral imaging (D0220), provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2790) provided April 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider payment. 
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 crown (D2790) provided April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) provided on April 19, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image and 2D oral/facial photographic image. You 
say that this is the first time you have submitted a claim in the last 10 years. You also say that you do not 
understand how the claim is denying for exceeding frequency. The Plan denied your request. The Plan says 
your benefit for the panoramic radiographic image has already been exhausted. The Plan also says the 2D 
oral/facial photographic image is not covered 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 2D oral/facial photographic image 
is 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) provided on April 19, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service April 19, 2023. The 
full mouth or panoramic x-rays are covered one procedure code every five calendar years. You already 
received the allowed frequency of one full mouth (D0210) on the appealed claim, and you also received an 
additional panoramic x-ray (D0330) at the same visit. Therefore, we decided that the Plan does not have to pay 
for a panoramic radiographic image (D0330), provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for bitewings (D0274), a 
periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composites (D2392), provided March 
22, 2023, to April 26, 2023. 
 
You asked the Plan to waive the copayment and coinsurance for D0274, D0120, D1110, and D2392. You say 
that you were unaware that you had these charges. 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 $15 
copayment and a 50% coinsurance for dental services.  
 
You have been asked to pay a $15 copayment D0274, D0120, and D1110 and a 50% coinsurance of the allowed amount for D2392. This item/service falls within the dental services 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 and coinsurance for bitewings (D0274), a periodic oral evaluation 
(D0120), prophylaxis (D1110), and resin-based composites (D2392), provided March 22, 2023, to April 26, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on January 26, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
code 99284.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99284.  
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 99284. Our reviewer says that the medical 
records do not support the billing of code 99284.  Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a high level. 
 
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 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photochromatic tinted lenses (V2744) purchased December 
20, 2022. 
 
You asked the Plan to pay for photochromatic tinted lenses (V2744). You say that the photochromatic lenses 
are medically necessary, not cosmetic. The Plan denied your request. The Plan says this service is not covered 
under the members contract under any normal circumstances. 
 
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 standard frames and lenses after cataract surgery as defined by Medicare. 
 
We looked at the file and the Plan's rules. The Plan rules also say that covered eyeglasses after cataract surgery 
includes standard frames and lenses as defined by Medicare. The Plan rules also say any upgrades are not 
covered (including, but not limited to, deluxe frames, tinting, progressive lenses or antireflective coating). 
Based on this information, we decided that the Plan's rules for coverage of photochromatic tinted lenses 
(V2744) have not been met. Therefore, we decided that the Plan does not have to pay for photochromatic tinted 
lenses (V2744) purchased December 20, 2022.
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 May 26, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
thought that you were having a heart attack and called 911. You also say that  the ambulance emergency 
medical team did an electrocardiogram and advised that you were not having a heart attack and did not need to 
go to the hospital. 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 May 26, 2023. 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 May 26, 2023.