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

 
We decided that the Plan does not have to pay for medical services provided on November 5, 2022. 
 
You asked the Plan to pay for medical services. You say that this should be covered. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on November 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing services (D4341). 
 
You asked the Plan to pre-approve 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 on date of service February 9, 2022. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing services 
(D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (D9222 and D9223) provided on December 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not have been able to get the 
procedures done without sedation. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because anesthesia is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
anesthesia (D9222 and D9223) provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and the resin-based composite (D2391) for tooth #31 provided on December 27, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that you exceeded your 
benefits for dental or else you would have waited to complete the dental services. The Plan denied your 
request. The Plan says your annual dental maximum 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 February 16, 2022, the Plan paid $1,032 for dental services. On March 9, 2022, the Plan paid $212 
for dental services. On April 7, 2022, the Plan paid $1,009 for dental services. On May 5, 2022, the Plan paid 
$66 for dental services. On June 3, 2022, the Plan paid $383 for dental services. On June 22, 2022, the Plan 
paid $127 for dental services. On December 8, 2022, the Plan paid $171 for dental services. For the year of 
2022 the Plan paid $3,000 ($1,032 paid + $212 paid + $1,009 paid + $66 paid + $383 paid + $127 paid + $171 
paid) for dental services; therefore, your annual dental maximum benefit for the year of 2022 was exhausted on 
the date of service of December 8, 2022. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140), the intraoral radiographic image (D0220), and the resin-based composite 
(D2391) for tooth #31 provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown repair (D2980) provided on February 7, 2023. 
 
You asked the Plan to pay for a crown repair. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 crown 
repair (D2980) provided on February 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home health services provided by an 
out-of-network provider from January 1, 2023, to January 26, 2023. 
 
You asked the Plan to waive the coinsurance for the home health services. You say that you did not know the 
provider was an out-of-network provider and you would like the Plan to cover the bill as an in-network claim. 
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 50% 
coinsurance for out-of-network home health care. On January 1, 2023, the total allowed amount was $248 with 
a coinsurance of $124 ($248 allowed x 50% coinsurance). Also, on January 1, 2023, the other charged total 
allowed amount was $272 with a coinsurance of $136 ($272 total x 50% coinsurance). On January 3, 2023, the 
total allowed amount was $248 with a coinsurance of $124 ($248 total x 50% coinsurance). On January 4, 
2023, the total allowed amount was $272 with a coinsurance of $136 ($272 total x 50% coinsurance). On 
January 6, 2023, the total allowed amount was $272 with a coinsurance of $136 ($272 total x 50% 
coinsurance). Also, on January 6, 2023, the other charged total allowed amount was $248 with a coinsurance of 
$124 ($248 total x 50% coinsurance). On January 9, 2023, the total allowed amount was $272 with a 
coinsurance of $136 ($272 total x 50% coinsurance). On January 10, 2023, the total allowed amount was $248 
with a coinsurance of $124 ($248 total x 50% coinsurance). On January 13, 2023, the total allowed amount was 
$272 with a coinsurance of $136 ($272 total x 50% coinsurance). On January 17, 2023, the total allowed 
amount was $272 with a coinsurance of $136 ($272 total x 50% coinsurance). Also, on January 17, 2023, the 
other total allowed amount was $2.27 with a coinsurance of $1.13 ($2.27 total x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance for the out-of-network home health services. This item/service 
falls within the home health agency 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 coinsurance 
for the home health services provided by an out-of-network provider from January 1, 2023, to January 26, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on January 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the consultation because it was 
needed for the re-treatment of a tooth. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the consultation is 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 a 
consultation (D9310) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service April 9, 2019. Specifically, the Plan 
provides coverage for one complete upper denture every 60 months.  
  
 
 
You previously received this dental item on April 9, 2019, less than 60 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the requested item at this time. Therefore, we 
decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve checkup examination (D0120), 1 x-ray (D0220) and an 
extra x-ray (D0230). 
 
You asked the Plan to pre-approve 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 on date of service February 1, 2023. 
Therefore, we decided that the Plan does not have to pre-approve checkup examination (D0120), 1 x-ray (D0220) and an extra x-ray (D0230).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation (A0130) provided on 
December 22, 2021. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that the claim was not paid and 
facility transport is covered under Medicare. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transportation (A0130) provided on December 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on October 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the inpatient hospital payment. 
 
The Plan must follow Medicare rules. Medicare rules say that patient transportation from one hospital or SNF 
to another is included in the inpatient payment. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are an ambulance transport 
from one hospital to another while the enrollee was inpatient. Payment for these services is included in the inpatient hospital payment. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete maxillary denture (indirect) (D5750) 
provided on January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel this should be a covered services under 
your insurance. 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 reline complete maxillary denture (indirect) (D5750) but is limited to one per 36-month period. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5750 on June 1, 2021. Therefore, this benefit was exhausted as of January 12, 
2023. Therefore, we decided that the Plan does not have to pay for reline complete maxillary denture (indirect) 
(D5750) provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve the Contour Next test strips. You say that the enrollee states the number on 
the contour machine are easier to read and they cannot see the numbers on the other machines, they are too 
small. The Plan denied your request. The Plan says only the preferred brand products listed in the Plan's 2023 
Diabetes Equipment and Supplies Coverage Policy are covered. 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Contour Next test strips. According to the Medicare rules for diabetes the physician must indicate the 
need for non-preferred test strips to qualify for tis medication. Therefore, we decided that the Plan does not 
have to pre-approve Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on January 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service November 
18, 2022. 
 You asked the Plan to pay for procedure code 93971. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93971 is bundled into payment for code 
93970. 
 
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 93971 
is a column II code to column I code 93970. 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 93971 billed for date of service November 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on August 23, 2022, to August 
31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services should be covered and paid 
by the Plan. 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 August 23, 
2022, to August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on December 7, 2022, billed 
with procedure code 78815-26-PS-GZ. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items submitted with a GZ modifier shall be 
denied automatically and will not be subject to complex medical review.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on December 7, 2022, billed with procedure code 78815-26-PS-
GZ.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service November 6, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 
70553. 
 
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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service November 6, 
2022.