Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the laboratory must see all the patients in 
the nursing home that need care. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. Also, the services provided were not emergent or urgent. 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 laboratory services provided on March 28, 
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 periodontal scaling and root planing, fluoride application, 
gingival irrigation services, and an unspecified periodontal procedure (D4921, D4999, D1206, D4341) 
provided on March 13, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Coverage for the gingival irrigation 
services and unspecified periodontal procedure denied correctly as they do not fall within your dental benefits, 
regardless of the providers network status. 
 
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 periodontal scaling and root planing, fluoride application, gingival irrigation services, and an 
unspecified periodontal procedure (D4921, D4999, D1206, D4341) provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230), diagnostic casts (D0470) and core buildup, including any pins when required (D2950) provided on 
April 4, 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 intraoral - periapical each additional radiographic 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 requested item or service was exhausted on date of service April 4, 2023. Diagnostic 
casts and core buildup are not a covered benefit. Therefore, we decided that the Plan does not have to pay for 
intraoral - periapical each additional radiographic image (D0230), diagnostic casts (D0470) and core buildup, 
including any pins when required (D2950) provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met.  
The Plan follows Medicare rules. Medicare rules say that oxygen and oxygen equipment are covered when 
specific criteria are met. 
 
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 a portable oxygen concentrator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the reviewed 
documentation indicates that the enrollee's blood oxygen level when checked in the emergency room never 
went below 90% on room air even with exertion. The review has determined that the enrollee does not meet the 
coverage criteria and the services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) and 
intraoral-periapical each additional radiographic image (D0230) provided on March 3, 2023. 
 
You asked the Plan to pay for intraoral-periapical first radiographic image and intraoral-periapical each 
additional radiographic image. 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 intraoral-periapical first radiographic image (D0220) and intraoral-periapical each additional radiographic image 
(D0230) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the walker (E0143) provided on December 13, 2022. 
 
You asked the Plan to pay for the walker (E0143). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the walker (E0143) based on Medicare criteria. The Local Coverage Determination and Article the 
Plan bases their denial on does not specifically state that the KX modifier must be billed with code E0143. 
Therefore, we decided that the Plan has to pay for the walker (E0143) provided on December 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011), and sinus augmentation with bone or bone substitutes via a lateral open approach 
(D7951). 
 
You asked the Plan to pre-approve the surgical access to an implant body and sinus augmentation. You say that 
you realize that these are not covered benefits. You also say that the provider said you need a sinus 
augmentation/bone graft or the implant will not be successful. The Plan denied your request. The Plan says you 
are only covered for the services, codes and limits listed in the Evidence of 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 
surgical access to an implant body (second stage implant surgery) (D6011), and sinus augmentation with bone 
or bone substitutes via a lateral open approach (D7951).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits (97168). 
 
You asked the Plan to pre-approve the therapy services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 11 sessions of occupational therapy and is 
currently performing a home routine, including compression of her lower extremities, and is stable with regards 
to her lymphedema in her lower extremities. Her measurements have not significantly changed since starting 
therapy on May 12, 2023, and she can continue with her home program and the pump for her lymphedema. 
Therefore, the additional 10 sessions of occupational therapy are not medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy visits (97168).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the autogenous connective tissue graft procedure 
(D4273). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically necessary 
because you have gum recession in your mouth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the autogenous connective tissue graft procedure is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
autogenous connective tissue graft procedure (D4273).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
January 31, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you feel there should 
not be a copayment for a routine vision examination. 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 $35 
copayment for Medicare-covered eye examinations to diagnose and treat diseases of the eye. 
 
You have been asked to pay a $35 copayment for a medical eye examination. This item/service falls within the Medicare-covered eye examinations to diagnose and treat diseases of the eye 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 provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on April 13, 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 April 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on February 05, 2023, to February 09, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with 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 a $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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 total you owe is $60 for the PT visits ($30 per visit x 2 visits = $60). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on February 05, 2023, to February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided on March 29, 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 March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraorifice barrier (D3911) for tooth #5 and #6 provided 
March 16, 2023. 
 
You asked the Plan to pay for D3911. You say that you would like to be fully reimbursed. The Plan denied 
your request. The Plan says the rendered dental service 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 an 
intraorifice barrier (D3911) for tooth #5 and #6 provided March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endodontic therapy, molar tooth (excluding final 
restoration) (D3330), and pay for the core buildup, including any pins when required (D2950) provided on 
March 30, 2023. 
 
You asked the Plan to pay more for the endodontic therapy. You also asked the Plan to pay for the core 
buildup, including any pins when required.  You say that the Plan only paid $281.00 of the $1,550.00 for the endodontic therapy, molar tooth which left 
you with a balance of $1.269.00. You also say that this included a charge of $400.00 for code D2950 which 
you say you are aware of is not covered. The Plan denied your request. The Plan says that the claim processed 
appropriately.  
 
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 core buildup, including any pins 
when required is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for core buildup, including any pins when required (D2950). 
 
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 the endodontic therapy, molar tooth 
(excluding final restoration) (D3330) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture sectioning (D9120) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that you have been trying to get a 
partial denture that will fit your mouth properly since last year. The Plan denied your request. The Plan says 
this service is not covered 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 fixed partial denture sectioning is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
fixed partial denture sectioning (D9120) provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of a dental implant (D6100) for tooth #2. 
 
You asked the Plan to pre-approve the dental service. You say that you obtained an upper denture implant, and 
you need the dental service to eat properly. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because dental implants and all associated services 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of a dental implant (D6100) for tooth #2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 19, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had a toothache and you found out that you 
were not covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the limited oral evaluation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided on March 23, 
2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. 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 supported 
as 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 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). 
 
We find that CPT codes 96365 and 96366 are not supported in the medical record. Specifically, the procedure 
report documents "Restor Metabolix uses the Nimbus Portable Infusion Pump. Novolin R with Saline is used 
for the treatment of Pre-diabetes, Type 1 Diabetes, Type 2 Diabetes, and Metabolic Syndrome". In this case, 
services denied correctly, as the incorrect codes were reported for the services documented. There is a more 
appropriate code to report for the services documented. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 96365 and 96366 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 96365 and 96366 provided on March 23, 2023.