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

 
We decided that the Plan does not have to pre-approve neurosurgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve neurosurgery. You say that you would prefer to go to Inspired Spine Health. 
The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neurosurgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care proved on November 30, 2022.
You asked the Plan to pay for this service. You say that you were visiting your daughter in
outside of Portland when you started experiencing heart irregularities. You say that you went the emergency
room, and the hospital immediately admitted you to the hospital. You say that the next day the doctor told you
that you may only have one more day to live. The Plan denied your request. The Plan says that the care was
received from an out-of-network provider without prior authorization.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health. The rules also 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. We decided that this case does meet prudent layperson criteria for
emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the
absence of immediate medical care to seriously jeopardize their health in this case. In addition, the Plan has not
made reasonable and diligent efforts to gather and forward us information needed for our review. The Plan did
not provide any medical records or evidence of having made reasonable attempts to obtain medical records.
Therefore, we decided that the Plan has to pay for inpatient hospital services provided on November 30, 2022.
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81227 and 81328) provided on November 1, 
2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81227 and 81328) provided on November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on December 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that the American Dental Association recommends 2 
oral exams and 2 oral cleaning per year. You also say that oral examination and cleaning are considered 
essential of oral care. 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 June 9, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 provided on August 18, 
2022. 
 
You asked the Plan to pay for procedure codes 87631 and 99072. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for procedure code 
87631 did not include the required unique identifier. Additionally, procedure code 99072 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for procedure code 87631. Additionally, we find that procedure code 99072 has a status indicator 
of B on the Physician Fee Schedule. This means that procedure code 99072 is not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 87631 and 99072 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87631 and 99072 
provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network office visit provided on 
March 2, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network office visit. You say that you were told this visit 
would be covered at 100% 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 $625 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
You have been asked to pay $92.28 towards that $625 deductible, which had not been met at the time of this 
visit. 
 
The item or service you asked the Plan to waive the coinsurance for falls within the Physician/Practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $625 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  This cost sharing is a contractual obligation that had not been met at the time an in-network office visit was 
received on March 2, 2023. Therefore, we decided that the Plan does not have to waive the coinsurance for an 
in-network office visit provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7140) for tooth #20, #21, #28, and 
#29 provided by an out-of-network provider on January 4, 2023. 
  You asked the Plan to pay more for the dental services. You say that you were told that extractions would be 
covered, and the Plan should pay the full cost for the dental services. 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. 
 
For each extraction the amount billed was $220 and the amount allowed was $93 leaving a difference of $127 
($220 billed - $93 allowed). The total difference for the 4 extractions was $508 ($127 difference x 4 
extractions). 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 the extractions (D7140) for tooth #20, #21, 
#28, and #29 provided by an out-of-network provider on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on January 
24, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D0120, D1110 and D0274. You 
say that you checked your enrollment booklet prior to receiving the services and it stated that cleaning, x-rays, 
and exam are fully covered up to a maximum benefit of $2,000 per year for in and out-of-network dentistry. 
You also say that you feel this does not reflect the coverage spelled out in your booklet. 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 a periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on 
January 24, 2023.  
 
Your complaint about the coverage spelled out in the booklet 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 an intraoral - complete series of radiographic images 
(D0210), and comprehensive oral evaluation - new or established patient (D0150) provided on February 17, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this dentist is part of the Plan's network and the 
provider confirmed this so the services should be covered. 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 an intraoral - complete series of radiographic images (D0210), and comprehensive oral evaluation - 
new or established patient (D0150) provided on February 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage.
You asked the Plan to pre-approve additional transportation mileage. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. The Plan has confirmed that necessary care is available within the limit of 60 mile limit. Therefore, we decided that the Plan does not have to pre-approve additional transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, intraoral x-ray, and 
periodontal maintenance provided on February 13, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Your benefit for intraoral x-rays has 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. 
 
 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 a periodic oral evaluation, intraoral x-ray, 
and periodontal maintenance provided on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on March 28, 2023. 
 
You asked the Plan to pay more 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 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 a periodic oral evaluation and cleaning 
(D0120, D1110) provided on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed tomography (CT), head or brain 
provided on February 15, 2023. 
 
You asked the Plan to waive the copayment for Computed tomography (CT), head or brain. You say that you 
were told there would be no copayment, so you feel you should not have to pay for the billed service. 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 $300 
copayment for diagnostic radiology services. 
 
You have been asked to pay a $300 copayment for Computed tomography (CT), head or brain. This 
item/service falls within the diagnostic radiology 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. However, since the allowed amount is less than the 
standard copayment, you only owe $122.60. Therefore, we decided that the Plan does not have to waive the 
copayment for Computed tomography (CT), head or brain provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and each additional radiographic image (D0230) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0220 and D0230. You say that the x-
rays were taken to support the decision to move forward to extract a molar. You also say that the x-rays were 
absolutely necessary for the decision for the extraction and should have been approved. The Plan denied your 
request. The Plan says these services are not covered under the enrollee's contract under any normal 
circumstances. 
 
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 an 
intraoral - periapical first radiographic image (D0220), and each additional radiographic image (D0230) 
provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 28, 2022. 
 
You asked the Plan to pay for the dental service. 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 service was exhausted on date of service October 27, 2022. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on 
November 28, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided to the enrollee on September 8, 2022.
You asked the Plan to pay for the emergency department visit. You say that the claim was billed with the appropriate code. The Plan denied your request. The Plan says that the code billed was not appropriate.
Medicare rules state that providers must bill appropriate codes. In this case the claim was billed with code 99285. However, based on the Medicare billing guidelines, the claim should have been billed with code 99284 based on the presentation of the enrollee to the emergency room. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided to the enrollee on September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on January 23, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your provider was out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic (D6740), and pontic - 
porcelain/ceramic (D6245) provided on February 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that are appealing the denial of payment for the 
dental services, due to you feel that it should be paid. The Plan denied your request. The Plan says your benefit 
for the requested services $1,500 dollar limit was met as the Plan has currently paid out the maximum allowed 
on this dental claim. 
 
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 services was exhausted on date of service February 6, 2023. Therefore, we 
decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic (D6740), and pontic - 
porcelain/ceramic (D6245) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete radiographic images (D0210) provided 
on February 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were referred to the dental provider from the 
Plan and if you knew they were out-of-network you would not have gone to them. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the intraoral complete 
radiographic images are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral complete radiographic images (D0210) provided on February 1, 2023.