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

 
We decided that the Plan does not have to pre-approve a dental visit 
 
You asked the Plan to pre-approve the dental visit. You say that you are asking to continue to see your dentist 
you have been seeing for 15-20 years although he is out-of-network. The Plan denied your request. The Plan 
says dental services from an out-of-network provider are not covered by your supplemental benefits. The Plan 
also says that there are participating providers in your network.  
 
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 are requesting 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 pre-approve a dental 
visit
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses (V2100) provided on March 31, 2023. 
 
You asked the Plan to pay for lenses (V2100). You say that you should not be responsible for $32. The Plan 
denied your request. The Plan says this benefit was exhausted with this service. The Plan also says that after 
they paid their $300, there was a member liability of $40. The Plan also says there was a discount of 20% off of 
the $40. 
 
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 $300 per calendar year for eyeglasses (prescription lenses, frames, a combination of 
lenses and frames) applied at the time of service. 
 
We looked at the file and the Plan's rules. The Plan rules say that if you choose a Plan vision care participating 
provider, you have the benefit of $300 per calendar year for eyeglasses (prescription lenses, frames, a 
combination of lenses and frames) applied at the time of service. The Plan rules also say that you would be 
responsible for the balance. The record shows the benefit was exhausted with this service, leaving a member 
liability of $40. The record also shows that there was a 20% discount was applied to the $40, thus leaving a 
balance of $32. Based on this information, we decided that the Plan's rules for coverage of lenses (V2100) have 
not been met. Therefore, we decided that the Plan does not have to pay for lenses (V2100) provided on March 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for deluxe frames (V2025), progressive lenses (V2781), 
polycarbonate lenses (V2784), photochromatic tint (V2744), and antireflective coating (V2750) provided on 
March 23, 2023. 
 
You asked the Plan to reimburse for deluxe frames (V2025), progressive lenses (V2781), polycarbonate lenses 
(V2784), photochromatic tint (V2744), and antireflective coating (V2750). You say that you paid the doctor in 
full at the time of the examination. You also say you want to be reimbursed what you are owed. The Plan 
denied your request. The Plan says the claim will not pay out the $200, as it is deducted from the total retail 
price/submitted charge to come up with your remaining responsibility. 
 
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 $200 toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 (combined in and out-of-
network) benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per 
calendar year). The record shows the benefit was exhausted with this service. Specifically, the $200 benefit was 
subtracted from this service/material. Based on this information, we decided that the Plan's rules for coverage 
of deluxe frames (V2025), progressive lenses (V2781), polycarbonate lenses (V2784), photochromatic tint 
(V2744), antireflective coating (V2750), and medical examination (90224)  have not been met. Therefore, we 
decided that the Plan does not have to reimburse for deluxe frames (V2025), progressive lenses (V2781), 
polycarbonate lenses (V2784), photochromatic tint (V2744), and antireflective coating (V2750) provided on 
March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 03, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the claim payment denial. 
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 wound care supplies 
provided on April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210) provided on May 5, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that the 
previous provider never took any full mouth x-rays. You also say that only five to six x-rays were taken. The 
Plan denied your request. The Plan says your benefit for the intraoral  comprehensive series of radiographic 
images 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 intraoral  comprehensive series of radiographic images was exhausted on date of 
service March 15, 2023. Therefore, we decided that the Plan does not have to pay for an intraoral  
comprehensive series of radiographic images (D0210) provided on May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83540 and 84153 provided on December 1, 
2022.  
You asked the Plan to pay for procedure codes 83540 and 84153. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, procedure codes 83540 and 84153, were requested solely for screening 
purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for procedure codes 83540 and 84153 provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on February 23, 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 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on February 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were assured there was sufficient 
remaining amount with the insurance to cover the final procedure. You say that you made it very clear that you 
could not afford any out-of-pocket responsibility. 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 $108 on date of service March 13, 2023, paid $470 on date of service February 14, 2023, 
and paid $2,422 on date of service February 14, 2023 ($108 + $470 + $2,422 = $3,000). After the annual 
maximum is exhausted, any remaining charges are your responsibility. Therefore, this benefit has been 
exhausted as of March 13, 2023. Therefore, we decided that the Plan does not have to pay more for dental 
services provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210), alveoloplasties in conjunction with extractions-four or more teeth or 
tooth spaces, per quadrant (D7310), bone replacement grafts for ridge preservation-per site (D7953), an interim 
complete upper denture (D5810), an interim complete lower denture (D5811), surgical removal of an implant 
body (D6100), a therapeutic parental drug, single administration (D9610), intravenous moderate (conscious) 
sedation/analgesia (D9239), intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute 
increment (D9243). 
 
  
 
 
 
You asked the Plan pre-approve these items/services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items/services are not covered under 
the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have pre-approve the 
extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), alveoloplasties 
in conjunction with extractions-four or more teeth or tooth spaces, per quadrant (D7310), bone replacement 
grafts for ridge preservation-per site (D7953), an interim complete upper denture (D5810), an interim complete 
lower denture (D5811), surgical removal of an implant body (D6100), a therapeutic parental drug, single 
administration (D9610), intravenous moderate (conscious) sedation/analgesia (D9239), intravenous moderate 
(conscious) sedation/analgesia-each subsequent 15 minute increment (D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth guard (D9940). 
 
You asked the Plan to pre-approve the mouth guard. You say that this guard stops your teeth grinding and your 
teeth are fractured because of it. You also say that this is an ongoing issue and is urgent. The Plan denied your 
request. The Plan says a mouth guard is not included within this coverage. 
 
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 pre-approve a 
mouth guard (D9940).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 12, 
2022. 
 
You asked the Plan to pay 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 the acute inpatient hospital care provided was 
not medically necessary.   
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for this service. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on September 11, 2022 
requesting dialysis. The enrollee is a resident of Ohio and traveled to California for a visit. The enrollee does 
his own dialysis at home and has a hemodialysis machine with him but has not received his dialysis fluids yet. 
The enrollee was admitted for dialysis and a nephrology consult. The enrollee was discharged on  
September 12, 2022. The review has determined that the record did not show that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99239 provided on September 26, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
billed. 
 
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 99239 is Hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is supported in the medical record. Specifically, the medical record shows that 
more than 30 minutes of hospital discharge day management was provided on September 26, 2022, by the 
provider. Based on this information, we decided that Medicare rules for coverage of procedure code 99239 
have been met. Therefore, we decided that the Plan has to pay for procedure code 99239 provided on 
September 26, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 15, 2023 to 
March 16, 2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 15, 2023. The NOA was not received by the Plan until May 16, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on February 15, 2023 to March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you need these dentures to eat and prevent 
your teeth from moving. 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 September 28, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and 
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need the Plan to approve 
this dental work since the denture you have is well deteriorated due to its age. You also say that you are 95 
years old and the teeth are essential to be able to feed yourself and have a better quality of life.  The Plan 
denied your request. The Plan says services considered not reasonable and necessary are not covered under any 
condition. 
 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 Plan covers the 
mandibular partial denture when the services are medically necessary and reasonable.  
 
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 mandibular partial denture. Our 
reviewer says that the mandibular partial denture is not medically necessary. Our physician reviewer found 
teeth numbers 22 and 23 are the only teeth present in your mouth. Review of the  panoramic x-ray shows 
severe bone loss around teeth numbers 22 and 23. Based off the limited documentation submitted, I agree with 
the plan that it would not be prudent to make a mandibular partial as the teeth that will be holding in the partial 
have a poor prognosis due to the amount of bone loss around these teeth. If these teeth were a loss or need to 
come out, the partial will no longer be of any use to you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the mandibular partial denture have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a mandibular partial denture - flexible base (including retentive/clasping 
materials, rests, and teeth) (D5226).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 12, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient on the date of service at issue. Therefore, we decided that the Plan does not have to pay 
for the ambulance services provided on August 12, 2022.