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

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953), 
guided tissue regeneration (D4266), deep sedation/general anesthesia each additional 15 minutes (D9223), 
therapeutic parenteral drug single administration (D9610) and the collection and application of autologous 
blood concentrate product (D7921) provided on February 20, 2023. 
 You asked the Plan to pay for bone replacement graft for ridge preservation (D7953), guided tissue 
regeneration (D4266), deep sedation/general anesthesia each additional 15 minutes (D9223), therapeutic 
parenteral drug single administration (D9610) and the collection and application of autologous blood 
concentrate product (D7921). You say that prior to having the services, you called the concierge, and they sent 
in something. You also say that you received two letters from the Plan indicating that the anesthetics would be 
covered, and the out-of-network surgery would be covered. The Plan denied your request. The Plan says the 
services rendered are not covered. 
 
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 bone 
replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266), deep sedation/general 
anesthesia each additional 15 minutes (D9223), therapeutic parenteral drug single administration (D9610) and 
the collection and application of autologous blood concentrate product (D7921) provided on February 20, 
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), an 
intraoral - periapical each additional radiographic image (D0230), and the topical application of fluoride 
(D1208) provided on April 21, 2023. 
 
You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), an intraoral - 
periapical each additional radiographic image (D0230), and the topical application of fluoride (D1208). You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says that they do 
not cover the service you are appealing. The Plan also says that these services are explicitly listed as being 
covered only under the optional supplemental dental plan, which you do not have.  
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), an intraoral - periapical each additional radiographic 
image (D0230), and the topical application of fluoride (D1208) provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (D5226) and 
a maxillary partial denture - flexible base (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that you need these prosthodontic services. 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 December 17, 2021. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base 
(D5226) and a maxillary partial denture - flexible base (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic images 
(D0230), and bone replacement grafts (D4264) provided from April 10, 2023, to May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were originally told your services were 
covered. You also say that at the appointment you were told these services were not covered and you had to 
pay upfront. The Plan denied your request. The Plan says your benefit for intraoral - periapical each additional 
radiographic images (D0230) have already been exhausted. The Plan also says that bone replacement grafts 
(D4264) are 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, certain limitations apply. The record 
shows your benefit for an intraoral - periapical each additional radiographic image (D0230) was exhausted on 
date of service April 10, 2023, to May 3, 2023. Also, though the Plan offers a dental benefit in excess of 
Medicare coverage, bone replacement grafts (D4264) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic 
images (D0230), and bone replacement grafts (D4264) provided from April 10, 2023, to May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on April 05, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you are not 
being treated for any eye or vision related illness. 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 $30 
copayment for each Medicare-covered examination. 
 
You have been asked to pay a $30 copayment for a medical eye examination (92014). This item/service falls 
within the each Medicare-covered examination benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a medical eye examination (92014) provided on April 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
September 8, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you have never been 
aware of the determination of refractive state charge. You also say that you were also not told by the provider's 
office. The Plan denied your request. The Plan says this is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine vision examination per year. Medical eye examinations and a 
determination of refractive state (92015) is excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that covered services include outpatient physician 
services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related 
macular degeneration. The Plan contract also says that Original Medicare doesnt cover routine eye exams (eye 
refractions) for eyeglasses/contacts. The Plan contract also says that the Plan covers one routine vision 
examination per year. The record shows this was not a routine eye examination. Based on this information, we 
decided that the Plan's rules for coverage of a determination of refractive state (92015) have not been met. 
Therefore, we decided that the Plan does not have to pay for a determination of refractive state (92015) 
provided on September 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 21, 
2023. 
 
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 the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bacterial urine culture testing provided on April 3, 2023. 
 
You asked the Plan to pay for bacterial urine culture testing. You say that this testing is clinically valuable and 
should be covered. The Plan denied your request. The Plan says you did not bill this testing with a covered 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that bacterial urine culture testing is only covered 
when billed with specific diagnoses.  The diagnosis you billed on this claim (R93.49) is not a covered 
diagnosis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bacterial urine culture testing have not been met. Therefore, we decided that the Plan does not have 
to pay for bacterial urine culture testing provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service March 28, 2023, with 
the following codes: 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 91306, 81328, 81335, 81479, 
and 81238. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and ordered 
by the patient's doctor. The Plan denied your request. The Plan says these lab services should have been billed 
as a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported.  
 
In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.   
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. Therefore, we decided that the Plan does not have to pay for lab 
services billed for date of service March 28, 2023, with the following codes: 81225, 81226, 81227, 81231, 
81232, 81240, 81241, 81291, 91306, 81328, 81335, 81479, and 81238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service August 29, 
2022.  
 
You asked the Plan to pay for procedure code 69990. You say that this claim was underpaid. The Plan denied 
your request. The Plan says payment for code 69990 is bundled into payment for code 35206. 
 
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 69990 
is a column II code to column I code 35206 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 69990 billed for date of service August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition requires 
the level of care provided at an LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and does not require a transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving all indicated care at the acute care hospital, which is 
approved. There are no specific treatments that the enrollee would receive at the LTACH that they are currently 
not receiving. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 the MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the patient has significant low back and sacral 
pain which has persisted despite 6 weeks of physical therapy. She has been evaluated face to face after therapy. 
Her persistent pain despite a 6-week course of therapy qualifies as a medically necessary requirement for the 
requested MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 24, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. 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 ambulance services provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
March 23, 2023. 
 
You asked the Plan to pay for this dental service. 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 service 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 service provided was exhausted on date of service February 18, 2019.  
  
 
 
Specifically, the Plans contract states that full mouth or panoramic x-rays are covered once every five years. 
You previously received full mouth x-rays on February 18, 2019, less than five years prior, which were paid for 
by the Plan. Therefore, you have exhausted the allowable benefit for the service provided in this case.  
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the health club membership 
(S9970) purchased on January 1, 2022. 
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have been 
reimbursed for your portion of the couples health club membership purchased; therefore, additional payment 
will not be issued.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.    
 
 
 
 
The Plans rules for additional coverage of gym benefits have not been met because the Plan previously issued 
reimbursement to you on May 12, 2023 for your portion of a couples health club membership purchased for 
the 2022 calendar year. The remaining balance owed is for your spouses portion of this membership; as he is 
not a member under your individual plan, the Plan is not liable for payment. Therefore, we decided that the 
Plan does not have to issue additional reimbursement for the health club membership (S9970) purchased on 
January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
February 24, 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 these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on February 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 05, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the scan was 
billed incorrectly and should have been a preventative lung-cancer screening. 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 outpatient diagnostic tests. 
 
You have been asked to pay a $300 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 total you owe is $111.50, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on April 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 87801, 87798, and 87493. 
 
You asked the Plan to pay for the lab services. You say that these codes are valid for the services performed. 
The Plan denied your request. The Plan says you should have billed these lab services as a single panel code 
instead of separate codes. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported for the procedure.  
 
In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.  
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services billed with codes 87801, 87798, and 87493.