Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on July 22, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that the current physician is the only person 
who can relieve the pain in your eye. The Plan denied your request. The Plan says that acupuncture is only 
covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received treatment in your eye, and acupuncture 
is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided on July 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown 
(D2954). 
 
You asked the Plan to pre-approve prefabricated post and core in addition to crown. You say that crown 
replacement is necessary for tooth longevity and structural integrity. The Plan denied your request. The Plan 
says there is no coverage for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
prefabricated post and core in addition to crown (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- 
first 15 minutes (D9239), and intravenous moderate (conscious) sedation/analgesia  each subsequent 15 
minute increment (D9243) provided on August 22, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this service is 
not covered in your dental 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 the 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous moderate 
(conscious) sedation/analgesia  each subsequent 15 minute increment (D9243) provided on August 22, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 tests provided on November 28, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you billed the correct diagnosis, and the 
COVID-19 tests were done during the public health emergency. The Plan denied your request. The Plan says 
that the tests are considered non-diagnostic. 
 
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. We find that the enrollee's diagnosis shows that this test would be considered 
medically necessary. The enrollee's diagnosis shows possible exposure to COVID-19.  Therefore, we decided 
that the Plan has to pay for the COVID-19 tests provided on November 28, 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 pay for the dental services provided on August 28, 2023 by an out-
of-network provider. 
 
You asked the Plan to pay for the dental services. You say that some provisions should be made for people like 
you who have such a good relationship with their provider. You say if the Plan could at least agree to pay for 
half the amount of the services, that would seem fair to you. 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 dental services provided on August 28, 2023 by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on June 15, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation provided supports an appropriate history or examination but does not support a high 
level of decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on June 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on March 26, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
procedure code 99285.  The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99285.  
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 procedure code 99285. Our reviewer says that the medical records do not support the billing of procedure code 99285.  Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on March 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable power scooter. 
 
You asked the Plan to pre-approve a foldable power scooter. You say that the enrollee received a new scooter 
in September 2023. You say that the enrollee was advised that it would need to be taken apart to be put in the 
car and then put back together upon arrival. You say that this is too much for the enrollee. You also say that the 
enrollee would like to swap out the current power scooter for a foldable scooter. The Plan denied your request. 
The Plan says the records show that the enrollee received a Group 2 power scooter on September 14, 2023. The 
Plan also says that the notes do not show that a foldable power scooter is appropriate. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a Group 2 power scooter. A Group 2 power scooter serves the same 
purpose as a foldable power scooter. Therefore, we decided that the Plan does not have to pre-approve a 
foldable power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 sensors. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensors. You say that the enrollee is a diabetic and has 
been seen by the treating physician in the last 6 months. The Plan denied your request. The Plan says a medical 
necessity has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the FreeStyle Libre 2 sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and topical application of 
fluoride varnish (D1206) provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are a diabetic. You also say it is imperative 
to your good health that your gums are cleaned more than twice a year. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. The Plan also says that topical 
application of fluoride varnish (D1206) 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, certain limitations apply. The record 
shows your benefit for periodontal maintenance (D4910) was exhausted on date of service May 18, 2023. 
Topical application of fluoride varnish (D1206) is excluded from this benefit. Therefore, we decided that the 
Plan does not have to pay for periodontal maintenance (D4910) and topical application of fluoride varnish 
(D1206) provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on August 31, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are unsure why you received a denial for the 
service when you never received a bill. You also say that this evaluation was on a single tooth. The Plan denied 
your request. The Plan says your benefit for the requested limited oral evaluation - problem focused 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 service was exhausted on date of service August 24, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided 
on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on 
September 6, 2023. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that the x-ray was necessary to 
diagnose and treat your tooth, and 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 May 1, 2023. Therefore, 
we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on 
September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 7, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you have been to the same office before, and 
they were not out-of-network. 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 for a limited oral evaluation (D0140) on November 9, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of November 9, 2022. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), and panoramic radiographic image (D0330) provided on August 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had a major infection while out of state. 
You also say that it was quicker to get it taken care of at a dentist rather than an emergency room only to be 
sent to a dentist which would be and less expensive. 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 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 comprehensive oral evaluation - new or established patient (D0150), and panoramic radiographic image 
(D0330) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical additional radiographic image 
(D0230) provided on August 2, 2023. 
 
You asked the Plan to pay for the dental service. You say that you called the plan and were advised that the x-
rays would be covered. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service August 2, 2023.  
 You already received the allowed frequency of one D0220 intraoral - periapical first radiographic image on the 
appealed claim. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical 
additional radiographic image (D0230) provided on August 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee improved with bilevel positive 
airway pressure (BIPAP) therapy and did not have failure of BIPAP. The documentation supports continued 
BIPAP therapy. Hence, there is no indication for a home ventilator per data provided. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on June 2, 2023 by an out-
of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that you dont think you should pay this 
invoice because they did not tell you they were not in the network and they accepted the insurance card also. 
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 the dental services provided on June 2, 2023 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), two dimensional (2D) oral or facial 
photographic images (D0350), and three dimensional (3D) dental surface scan (D0801) provided on September 
21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told they were going to charge 
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 March 21, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274), two dimensional (2D) oral or 
facial photographic images (D0350), and three dimensional (3D) dental surface scan (D0801) provided on 
September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia (D9222, D9223) 
provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel this should be a covered service since it 
was done in the dentists office. 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 deep sedation/general anesthesia (D9222, D9223) provided on June 28, 2023.