Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in respiratory failure and 
is connected to a ventilator. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 that the enrollee appears to still be somewhat unstable and should only require short-
term acute care services that can safely be completed at the current facility until more stable and appropriate for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility.  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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on February 
13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentures are not fitting you comfortably. 
You went back to the dentist, and although they filed your teeth down, the dentures still did not fit you. 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 29, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on 
February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and a specialist visit provided 
on April 24, 2023. 
 
You asked the Plan to waive the cost share for an injection and a specialist visit. You say that you are unable to 
afford the cost share applied. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $45 copayment for each specialist office visit.  You have been asked to pay $46.52 for an injection and a specialist visit. This total includes $1.52 coinsurance, 
which is 20% of the allowed amount for a Medicare Part B drug injection ($7.60 allowed x 20% = $1.52) and a 
$45 copayment for a specialist visit. The injection falls within the Medicare Part B prescription drugs benefit 
category. The specialist visit falls within the 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. Therefore, we decided that the Plan 
does not have to waive the cost share for an injection and a specialist visit provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954) 
provided on April 17, 2023. 
 
You asked the Plan to pay for a prefabricated post and core in addition to crown (D2954). You say that you had 
an abscess tooth and the dentist you went to did nothing. The Plan denied your request. The Plan says this 
service is not a covered expense under your 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 a 
prefabricated post and core in addition to crown (D2954) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain onlay restoration (D2643) for tooth #31. 
 
You asked the Plan to pre-approve the dental service. You say that you need the request restoration to prevent 
you from getting an implant. The Plan denied your request. The Plan says the records do not show that tooth 
#31 has any damage due to decay or fracture; therefore, the requested restoration is denied. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the porcelain onlay restoration (D2643) for tooth #31 is not necessary or reasonable. Our physician 
reviewer found that the provided records do not include an adequate dental history to approve coverage as 
required by the supplemental dental coverage plan.  
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a porcelain onlay restoration (D2643) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional routine transportation trips. 
 
You asked the Plan pre-approve the additional trips. You say that the request is essential as you have to comply 
with medical visits to treat your multiple conditions. You also say that you have over 5 monthly visits with 
multiple physicians and specialists. The Plan denied your request. The Plan says the evidence shows you have 
used thirty-two (32) one-way trips of the thirty-two (32) one-way trips covered by your plan for the year 2023. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation for your medical appointments. Based on this information, we decided that 
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary (D5225) and a partial mandibular 
(D5226) denture. 
 
You asked the Plan to pre-approve the dental services. You say that you had surgery and your dentures no 
longer fit. 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 30, 2021. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary (D5225) and a partial 
mandibular (D5226) denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of a benign lesion (D7410) provided on April 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 
excision of a benign lesion (D7410) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
March 20, 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 March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274) and 
an adult prophylaxis (D1110) provided on March 7, 2023. 
 
You asked the Plan to pay for a periodic oral evaluation (D0120), bitewings (D0274) and an adult prophylaxis 
(D1110). You say that the denial of this claim was not justified so you are appealing the denial. The Plan 
denied your request. The Plan says the member is not enrolled in any additional dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120), bitewings (D0274) and an adult prophylaxis (D1110) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia for a dental procedure (D9215) provided on 
April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 local 
anesthesia for a dental procedure (D9215) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366), insulin (J1817), and pump 
maintenance (96521) billed for date of service February 22, 2023. 
 
You asked the Plan to pay for infusion services, insulin, and pump maintenance. You say that these services 
were billed correctly. The Plan denied your request. The Plan says these codes are not supported. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code J1817 is insulin for administration 
through durable medical equipment (i.e., insulin pump) per 50 units. The definition of code 96521 is refilling and maintenance of portable pump. 
 
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 infusion services, insulin, and pump maintenance. Our 
reviewer says that these codes are not supported. Our reviewer found the medical records provided indicate 
outpatient intravenous insulin treatment was performed. There is a more appropriate code for this service than 
codes 96365, 96366, and J1817. Although the documentation includes a physician order for refilling and 
maintenance of portable pump, documentation does not support service was performed to support 96521. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion services, insulin, and pump maintenance have not been met. Therefore, 
we decided that the Plan does not have to pay for infusion services (96365, 96366), insulin (J1817), and pump 
maintenance (96521) billed for date of service February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral 
comprehensive series of radiograph image (D0210), oral hygiene instructions (D1130) and topical application 
of fluoride (D1208) provided on May 11, 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 comprehensive oral evaluation and intraoral comprehensive series of 
radiograph image 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 comprehensive oral evaluation was exhausted on date of service October 23, 2020. 
Your benefit for the intraoral comprehensive series of radiograph image was exhausted on November 15, 2022. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral 
comprehensive series of radiograph image (D0210), oral hygiene instructions (D1130) and topical application 
of fluoride (D1208) provided on May 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 09, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were not 
advised that there would be a copayment for the ER visit. 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 $90 
copayment for Emergency Care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the Emergency 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. The total you owe is $74.08, which is less than the standard copayment for an ER visit. Therefore, 
we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service March 31, 
2023. 
 You asked the Plan to pay for code 99213-25. You say that this was billed correctly. The Plan denied your 
request. The Plan says this is not separately payable. 
 
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 99213 is a column II code to column I code 20610; however, 99213 
was billed with a modifier.  
 
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 code 99213-25. Our reviewer says that the records do not 
support code 99213 is separately payable. Our reviewer found code 99213 was billed with modifier 25 to 
indicate a significant, separately identifiable evaluation and management (E/M) service. However, the 
documentation does not support a significant identifiable E/M service, so this service was unbundled. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99213-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99213-25 billed for date of service March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a partial lower 
denture (D5214), and an extraction (D7140) for tooth #17. 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures because the old 
dentures hurt your mouth when eating. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because dentures and extractions are 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 pre-approve a 
complete upper denture (D5110), a partial lower denture (D5214), and an extraction (D7140) for tooth #17.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and does not have to waive 
the deductible for the re-cement of a crown (D2920),, provided on March 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an exposed root and you needed to get 
this procedure done as soon as possible. The Plan denied your request. The Plan says these services have been 
correctly applied. 
 
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 services February 7, 2023. A $50 deductible has been applied correctly to D2920. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) and does not have to waive the deductible for the re-cement of a crown 
(D2920), provided on March 17, 2023.