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

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on August 24, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you never had a tetanus shot given to you. The 
Plan denied your request. The Plan says the vaccine services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records show that a Tdap vaccine was administered on the date of service in this case. Records do not show 
that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we 
decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on August 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided on June 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 5, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that two visits were provided on same 
day. The Plan denied your request. The Plan says no records have been received to support the services for two 
visits on the same day. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 7, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on  
June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on July 12, 
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 on date of service January 10, 2023. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0272) provided on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed the service done. You also say the 
Plan wants you to go to the dentist but refuses to pay. 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 March 6, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0272) provided on September 18, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post and core in addition to crown (D2952) provided on May 
16, 2023. 
 
You asked the Plan to pay for post and core in addition to crown (D2952). You say that you filled all the 
necessary paperwork with hopes that the Plan dental advantage would pay all your claims for dental work. You 
also say you had no idea you had to get the prior authorization. The Plan denied your request. The Plan says 
post and core in addition to crown (D2952) 
 
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 post and 
core in addition to crown (D2952) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on February 2, 2023, to 
March 9, 2023. 
 
You asked the Plan to pay for a core buildup. 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 core 
buildup (D2950) provided on February 2, 2023, to March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 11, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided 
on August 10, 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 on date of service August 10, 2023. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) 
provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 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 on date of service July 8, 2021. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services (99453, 99454) provided on 
February 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the remote monitoring services. You say that no authorization was needed from 
the portal communication. You also say that the services were medically necessary. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
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 the remote monitoring services (99453, 99454) 
provided on February 22, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal 
(45385) provided on August 23, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that you called 
multiple times to verify that you would not owe anything for a routine colonoscopy. 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 $200 
copay per visit, per provider, per day for surgery performed in an outpatient hospital setting under the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. 
 
You have been asked to pay a $200 copay per visit for the colonoscopy with lesion removal. This service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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. The record shows that you called customer service on February 8, 2023, and asked what your benefits 
were for a routine colonoscopy in which the customer service representative advised there was no cost share for 
a routine colonoscopy. However, the 2023 EOC clearly states if the screening test results in a biopsy or 
removal of a lesion or growth, the procedure is considered diagnostic and outpatient surgery cost sharing may 
apply. The specific code at appeal (45385) reflects that you received a lesion removal with your colonoscopy. 
Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy with lesion 
removal (45385) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341) provided on March 9, 2023 and March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service February 8, 2022.  
  
 
Specifically, the Plans contract states that periodontal scaling and root planing is covered once every twenty 
four months. You previously received this service on February 8, 2022, less than twenty four months prior, 
which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the services at issue. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing-four or 
more teeth per quadrant (D4341) provided on March 9, 2023 and March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D5110, D5120) on August 22, 2023. 
 
You asked the Plan to pay for the dental services (D5110, D5120). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 dental services (D5110, D5120) on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on August 8, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that you 
only went to the dentist for a cleaning and nothing was done to your mouth except for x-rays which were not 
requested. The Plan denied your request. The Plan says this service is not a covered expense 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral  
comprehensive series of radiographic images (D0210) provided on August 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided from January 
31, 2023, to March 20, 2023, by an out-of-network (OON) provider.  
  You asked the Plan to pay for the chronic care management services. You say that you thought prior 
authorization was obtained. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. Also, the services rendered were not urgent or emergent. 
 
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 the chronic care management services provided 
from January 31, 2023, to March 20, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 12, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. 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. Therefore, we decided 
that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-evaluation post-operative office visit (D0170) provided on 
July 11, 2023. 
 
You asked the Plan to pay for re-evaluation post-operative office visit. 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 re-
evaluation post-operative office visit (D0170) provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the upper complete denture (D5110) and the lower 
complete denture (D5120) provided on July 18, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says that the dental items at issue are 
not covered under the supplemental dental policy.  
 
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. Specifically, the Plan has not submitted the required Evidence of Coverage 
(EOC) contract. The Plan has not demonstrated that the items at issue in this case are non-covered. The Plan 
has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has 
to issue reimbursement for the upper complete denture (D5110) and the lower complete denture (D5120) 
provided on July 18, 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 gingival irrigation (D4921) provided on July 7, 2023. 
 
You asked the Plan to pay for gingival irrigation (D4921). You say that you are appealing with supporting 
records. 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 gingival 
irrigation (D4921) provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add a tooth service to existing partial denture (D5650) 
provided on August 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that you chose to have teeth added to the present 
partial because you wish to keep the real teeth you already have. You also say that a set of dentures and present 
teeth removal would be much more expensive and have a chance of infection. The Plan denied your request. 
The Plan says there is no coverage for add tooth to existing partial denture. 
 
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 add a 
tooth service to existing partial denture (D5650) provided on August 23, 2023.