Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace provided on January 27, 
2023. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you had no idea what the cost 
would be. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee brace. This item/service falls within the durable 
medical equipment and related supplies 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 $109.37 ($546.84 allowed amount x 20% = $109.37). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the knee brace provided on 
January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the hearing aids (V5050) purchased on 
December 29, 2022. 
 
You asked the Plan to issue additional payment 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 you have 
exhausted the allowable benefit for these items. 
 
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.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional payment of these items have not been met. Specifically, the Plans contract provides coverage for 
hearing aids every year in the amount $3,000. The Plan previously issued payment in the amount of $3,000 for 
these items. Therefore, you have exhausted the allowable hearing aid benefit. The Plan contract states that if 
you purchase hearing aids that cost more than what the Plan covers, you must pay the difference.  
  
Therefore, we decided that the Plan does not have to issue additional payment for the hearing aids (V5050) 
purchased on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apicoectomy, intraorifice barrier, and local anesthesia 
(D3421, D3911, D9215). 
 
You asked the Plan to pre-approve 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 dental services from an out-of-network 
provider are not covered by your supplemental benefits. Coverage for the local anesthesia 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. 
 
 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 
apicoectomy, intraorifice barrier, and local anesthesia (D3421, D3911, D9215).
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 February 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that there was 
no need for you to go to the hospital because you were feeling better. 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 February 15, 2023. 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 February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 13, 2022. 
 
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 $1,000 annual maximum limit has 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on December 13, 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 November 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you didnt 
realize that the service would not be covered if there was no transport. 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 November 5, 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 with no 
transport provided on November 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant (D6114) for tooth #1 provided by an out-of-
network and an unassigned provider on November 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider is an in-network provider, and the 
dental service is a covered benefit. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network and not the enrollee's assigned 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 and not your 
assigned dental 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 and from 
an unassigned dental provider. Therefore, we decided that the Plan does not have to pay for an implant (D6114) 
for tooth #1 provided by an out-of-network and an unassigned provider on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4267), bone replacement 
graft (D7953), collection and application of autologous blood concentrate product (D7921), deep 
sedation/general anesthesia (D9223 & D9222), and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve guided tissue regeneration, bone replacement, collection and application of 
autologous blood concentrate, anesthesia, and therapeutic drugs. You say that this should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 guided tissue regeneration (D4267), bone replacement graft (D7953), collection and application of autologous 
blood concentrate product (D7921), deep sedation/general anesthesia (D9223 & D9222), and therapeutic 
parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve partial upper denture (D5214). 
 
 
You asked the Plan to pre-approve partial upper denture. You say that this should be covered. The Plan denied 
your request. The Plan says that 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. The Plan covers partial upper 
dentures when meeting certain criteria. 
 
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 partial upper denture have been met. Therefore, we decided that the Plan has to 
pre-approve partial upper denture (D5214). 
  
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 pay for the periodontal scaling and root planing (D4341) and the 
unspecified periodontal procedure (D4999) provided by an out-of-network provider on December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that they got approval for 
the dental services. 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 the periodontal scaling and root planing (D4341) and the unspecified periodontal procedure (D4999) 
provided by an out-of-network provider on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by on January 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the denied dental service 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 the date of service of January 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by on 
January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (cutaneous squamous cell carcinoma), mRNA 
gene expression profiling by RT-PCR of 40 genes (0315U) provided June 30, 2022. 
 
You asked the Plan to pay for the DecisionDX-SCC test. You say that you are requesting your claim to be 
reprocessed and paid. The DecisionDX-SCC test is a covered Medicare benefit. The Plan denied your request. 
The Plan says this test is considered experimental and investigational as the test does not have enough evidence 
that this test has high quality validity. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the DecisionDX-SCC test have not been met. Therefore, we decided that the Plan does not have to 
pay for the oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 
genes (0315U) provided June 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 January 26, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the claim 
should be paid because if you went to urgent care, it would be paid. 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 January 26, 2023. 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 January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on January 18, 2023. 
 
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 this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant for tooth #9 and #10, and second 
stage implant surgery (D6011) for tooth #9 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that you have been waiting two years for this. 
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 with the approval of D6010 and D6011 for tooth #3. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant for tooth #9 
and #10, and second stage implant surgery (D6011) for tooth #9 and #10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-segmented pneumatic compressor (E0650) and 
segmental pneumatic appliance (E0673) provided January 18, 2022. 
 
You asked the Plan to pay for intermittent limb compression device and appliances. You say that the physician 
ordered this medically necessary durable medical equipment to be used in conjunction with the enrollee's 
surgery. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for peripheral artery disease and deep venous thrombosis prevention. Pneumatic compression device 
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The records show that the pneumatic compression device is being requested for peripheral artery 
disease and deep venous thrombosis prevention. Therefore, we decided that the Plan does not have to pay for 
non-segmented pneumatic compressor (E0650) and segmental pneumatic appliance (E0673) provided January 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) rendered 
from May 25, 2022, to May 27, 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 Current Procedural Terminology (CPT) code 99232 (1 unit) remains 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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 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 enrollee was treated in the 
hospital from 5/25/22 to 5/27/22 for a fall, hip fracture requiring surgery and complicated by anemia. Code 
99232 was submitted for these dates. The provided records did not include evidence of an appropriate history 
of physical or medical decision making of moderate complexity for the specific dates above. Also, there was no 
documented record of 25 minutes or more time spent providing the services on these same dates. 
 
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 subsequent hospital care (procedure code 99232) rendered from May 25, 2022, to May 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291 and 99292) 
rendered on December 14, 2021. 
 
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 the records do not support these services. 
 
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 the denied codes is: 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes  
CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service) 
 
 
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 provided documentation from 
this date did not clearly describe the duration of time services were rendered to meet the time requirements for 
these codes. Therefore, the records do not support the use of these codes in this case. 
 
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 critical care services (procedure code 99291 and 99292) rendered on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).