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

 
We decided that the Plan does not have to pay for the office visit and the radiological services provided on 
March 22, 2023, to April 3, 2023. 
 
You asked the Plan to pay for the office visit and the radiological services. You say that you have been fighting 
to get these services paid since April 3, 2023. You say that you and your spouse went to the same chiropractor 
and had the same services done but they were covered, and you were not. The Plan denied your request. The 
Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
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 and the radiological services provided on March 22, 2023, to 
April 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ED services provided on July 13, 2023. 
 
You asked the Plan to waive the copayment for ED services. You say that you want to know if you owe the 
copayment since you received conflicting information. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for ED services. 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. Therefore, we decided that the Plan does not have to waive the copayment for ED services provided on July 13, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on April 22, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
procedure code 99284. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99284. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
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 99284. Our reviewer says that the medical records do not support the billing of procedure code 99284. Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a moderate 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 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on April 22, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue additional payment for the porcelain/ceramic dental crowns (D2740 x 2) 
and the resin-based composite-two surfaces, anterior (D2331) provided on April 25, 2023. 
 
You asked the Plan to issue additional payment for the dental items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that your benefit 
for the items provided has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, the Plan has not provided substantiative evidence that demonstrates your 
benefit for the dental items provided has been previously exhausted. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to issue additional payment for 
the porcelain/ceramic dental crowns (D2740 x 2) and the resin-based composite-two surfaces, anterior (D2331) 
provided on April 25, 2023.  
 
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 x 3) and 
periodontal scaling and root planing (D4342) provide don March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the office provided an estimate. You also say 
that you believed this claim would be partially paid for. The Plan denied your request. The Plan says your 
benefit for these services 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 scaling and root planning for the upper left and upper right quadrants was exhausted 
on date of service January 24, 2022, and for the lower quadrants on date of service January 25, 2022. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 
3) and periodontal scaling and root planing (D4342) provide don March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), and intraoral x-rays (D0230) provided on August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have not had any covered visit or x-ray 
claims filed in 2023. You also say that there is no reason these services should not be covered. The Plan denied 
your request. The Plan says your benefit for these services have 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 September 7, 2022. The record shows your benefit for the panoramic x-ray was exhausted on date of service March 3, 2022. The 
record also shows your benefit for the intraoral x-ray was exhausted on the date of service in this case. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 
panoramic x-ray (D0330), and intraoral x-rays (D0230) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4) provided on June 8, 2022 and June 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided in this case are not 
covered under the supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing-four or 
more teeth per quadrant (D4341 x 4) provided on June 8, 2022 and June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000 x 2) provided on September 11, 
2023.  
 
You asked the Plan to pay 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 a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace.  
  
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Additionally, Medicare rules say that with the exception of the situations described, 
orthopedic footwear billed using code L3000 will be denied as noncovered. Therefore, we decided that the Plan 
does not have to pay for the foot orthotics (L3000 x 2) provided on September 11, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 2, 2023, through 
March 4, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was admitted with atelectasis and reactive lymphadenopathy. His fever resolved 
overnight. His condition stabilized and improved and he was discharged home on March 4, 2023 when 
considered medically stable. The review has determined that the record showed that at the time of the inpatient 
admission it was reasonable for the admitting physician to expect that the enrollees necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights with 
supporting documentation of the enrollees history and comorbidities, signs and symptoms, current medical 
needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from March 2, 2023, through March 4, 2023.  
 
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 periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that this service was routine dental cleaning and 
examination. You also say that routine services are covered by the insurance plan twice per year. 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, the Plan offers a $1,275 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on April 25, 2023, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extractions, erupted tooth or exposed 
root provided on April 11, 2023. We also decided that the Plan does not have to pay for the full mouth 
debridement provided on April 11, 2023. 
 
You asked the Plan to waive the coinsurance for the extractions. You also asked the Plan to pay for the full 
mouth debridement. The Plan denied your request. The Plan says the coinsurance was appropriately applied to 
the extractions. The Plan also says the full mouth debridement is not covered under the dental benefits. 
 
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 50% 
coinsurance for extractions when provided in-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay 50% coinsurance for the extractions that were received from an in-network 
provider. This service falls within the extractions 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 
coinsurance for the extractions, erupted tooth or exposed root provided on April 11, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the full mouth debridement is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that there is no way to evaluate your progress without this. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of IGRT have been met. Your treating 
provider did not submit supporting records to the Plan for review. The Plan made attempts to obtain supporting medical records, but none were submitted. Without supporting medical records, we cannot determine whether 
the requested IGRT is medically reasonable and necessary for you at this time. Therefore, we decided that the 
Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), topical application of fluoride 
varnish (D1206), core buildups (D2950 x 2), pontics (D6245 x 2) and retainer crowns (D6740 x 4) provided 
from May 19, 2023, to August 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to go to a new provider because your 
tooth kept falling out and you were not satisfied with your previous provider. 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 19, 2023. Therefore, 
we decided that the Plan does not have to pay for the prophylaxis (D1110), topical application of fluoride 
varnish (D1206), core buildups (D2950 x 2), pontics (D6245 x 2) and retainer crowns (D6740 x 4) provided 
from May 19, 2023, to August 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on July 29, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
the ambulance for your husband, but you were checked out by the emergency medical technicians while they 
were there. You also say that you did not specifically call them for yourself. The Plan denied your request. The 
Plan says the available information shows that you were evaluated, and you declined transport to the 
emergency room. The Plan also says that this request is 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 July 29, 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 (A0998) provided on July 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor, a full leg segmental pneumatic appliance, and 
segmental pneumatic appliance, trunk to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) to be provided 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on September 12, 2023. 
 
You asked the Plan to pay for  the acupuncture services. You say that according to the enrollee's acupuncture 
benefits, routine acupuncture services are handled by the Plan. The Plan denied your request. The Plan says the 
acupuncture services were provided by an unqualified provider. 
 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, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for  the acupuncture services provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on September 12, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you should have coverage for these services. 
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, the Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on February 21, 2023, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), 
prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on September 12, 2023.