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

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on January 17, 2023 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you received an x-ray on 
April 2021 and you also did not realize you could request x-rays from other providers. 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 intraoral - complete series of radiographic images (D0210) but is limited to one procedure every 
three plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered intraoral - complete series of radiographic images (D0210) on date of April 21, 
2021. Therefore, these benefits were exhausted as of January 17, 2023. Therefore, we decided that the Plan 
does not have to pay for intraoral - complete series of radiographic images (D0210) provided on January 17, 
2023
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the remote physiologic monitoring treatment management services, 
clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive 
communication with the patient/caregiver during the month (99457) provided on January 25, 2022. 
 
You asked the Plan to pay for the monthly telehealth service. You say that this service should be covered. The 
Plan denied your request. The Plan says that the frequency limit has been exceeded. 
 
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 supported the denial. The record does not support 
that this service has been performed or paid within the same calendar month as the date of service in this case. 
Without this information, it cannot be determined that the frequency limitation has been exceeded. Therefore, 
we decided that the Plan has to pay for the remote physiologic monitoring treatment management services, 
clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive 
communication with the patient/caregiver during the month (99457) provided on January 25, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and related services provided 
on December 2, 2022. 
 
You asked the Plan to pay for the emergency department visit and related services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not payable as 
billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit and 
related services provided on December 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 29, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you did not require additional medical care. 
You say that you decided not to be transported. You also say that you did not know this was a reason for the 
claim to be denied. The Plan denied your request. The Plan says ambulance response with no transport is 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 November 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told this would 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 dental services provided on January 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on November 
30, 2022. 
 
You asked the Plan to pay for the dental service. You say that they did not do a cleaning and you have a filling 
when visiting the provider. 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 the Plan paid for 2 dental exams on March 9, 2022, and April 27, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 27, 2022. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120) provided on November 30, 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 December 27, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
appealing the denial as you say the services were not requested. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 27, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought this would still 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 dental services provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99223 is included in the global day period of CPT 47562; this means it cannot be separately 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record does not 
include documentation of an evaluation and management service provided. The medical record includes flow 
sheet for vital signs.  In this case, an evaluation and management service documenting decision for surgery 
cannot be verified, as this procedure was not found in medical record submitted for review. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 6, 2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. We find that CPT code 84439 and 84443 are not covered for the 
diagnoses billed. The remaining codes are packaged services when billed with code 96413. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing billed for date of service December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
 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. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth specialist visit provided on 
January 16, 2023. 
 
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that you were not told 
you would be charged for a phone conversation. 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 $25 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $25 copayment for the telehealth specialist visit. This item/service falls within 
the specialist physician/practitioner 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. The specialist office visit copayment applies to telehealth services. 
Therefore, we decided that the Plan does not have to waive the copayment for the telehealth specialist visit 
provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan prior to your appointment, 
and you were told the services would 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. This benefit includes the 
requested panoramic radiographic image (D0330) but is limited to one procedure code every five calendar 
years. Consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9310 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on January 10, 2023. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered panoramic 
radiographic image (D0330) on November 16, 2021. Therefore, these benefits were exhausted as of January 10, 
2023. Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) 
provided on January 10, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from a structured 
environment where occupational and physical therapy is available. The Plan denied your request. The Plan says 
that the enrollee's records do not show the need for complex daily nursing. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that the enrollee has had medical and functional status 
change and would require assessment by skilled nursing and skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve resin-based composite - three surfaces, anterior (D2332) 
provided on December 27, 2022. 
 
You asked the Plan to pre-approve dental services. You say that you feel your insurance should have covered 
the billed service. The Plan denied your request. The Plan says this service is not covered under your Plan 
under any normal circumstance. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve resin-based composite - 
three surfaces, anterior (D2332) provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment  includes placement (D6057), 
and abutment supported porcelain fused to metal crown (noble metal) (D6061) provided on January 11, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6057 and D6061. You say that you 
were informed that crowns were covered. You also say that you are appealing the total amount that you owe 
that is reflected in the Explanation of Benefits. The Plan denied your request. The Plan says these services are 
not covered under the Plan's benefit package. The Plan also verified based on the information you were given 
on the phone calls, the Plan does cover crowns, however not the dental codes D6057 and D6061. 
 
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 custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain fused to metal crown 
(noble metal) (D6061) provided on January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF level of care to reach 
their maximum potential. The Plan denied your request. The Plan says the requested IRF admission is not 
medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.