Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), excision of benign lesion up to 1.25 cm (D7410), excision of benign lesion greater than 1.25 cm 
(D7411), deep sedation/general anesthesia  first 15 minutes (D9222) x2 and deep sedation/general anesthesia 
 each subsequent 15-minute increment (D9223) provided on January 18, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment for the 
services you received. The Plan denied your request. The Plan says these services are not covered under your 
Plan. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Comprehensive oral 
evaluation - new or established patient, excision of benign lesion up to 1.25 cm, excision of benign lesion 
greater than 1.25 cm, deep sedation/general anesthesia  first 15 minutes and deep sedation/general anesthesia 
 each subsequent 15-minute increment are not covered under the Plans dental benefits 
 
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 
comprehensive oral evaluation - new or established patient (D0150), excision of benign lesion up to 1.25 cm 
(D7410), excision of benign lesion greater than 1.25 cm (D7411), deep sedation/general anesthesia  first 15 
minutes (D9222) x2 and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) 
provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 billed for date of service March 2, 
2023. 
 You asked the Plan to pay for procedure code 93306. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93306 is bundled into payment for code 93351. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93306 
is a column II code to column I code 93351. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93306 billed for date of service March 2, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 27, 2023. 
 You asked the Plan to pay for the lab services. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says that Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 20, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214, G0439, 99397) provided on 
December 21, 2022. 
 
You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 99214, G0439, & 99397 are not supported in the medical record. Specifically, the 
codes billed are mutually exclusive and not billed with appropriate modifiers. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99214, G0439, 99397) provided on December 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs, self-administered from April 2, 2023, through 
April 6, 2023. 
 
You asked the Plan to pay for the medication. You say that the drug amount should be paid by insurance. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the drugs, self-administered from 
April 2, 2023, through April 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on April 18, 2023, to 
April 20, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services should be covered. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on April 18, 2023, to April 20, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a 
cleaning (D1110) provided on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware your preventive dental 
services were a part of the benefit maximum that was reached. The Plan denied your request. The Plan says 
your annual dental maximum benefit for the year 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 $426.93 for dental services on January 11, 2023. On January 17, 2023, the Plan paid 
$573.07. For the year of 2023 the Plan paid $1,000 ($426.93 paid + $573.07 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
January 17, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), bitewings (D0274), and a cleaning (D1110) provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and each additional radiographic image (D0230) provided on April 25, 2023. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image and each additional 
radiographic image. You say that you are asking the Plan to pay the provider for the x-rays as you see the 
dentist every 6 months. The Plan denied your request. The Plan says services D0220 and D0230 are not 
included in the list of 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  services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral - 
periapical first radiographic image (D0220), and each additional radiographic image (D0230) provided on 
April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elevating legrests (K0195) provided on June 25, 2021. 
 
You asked the Plan to pay for the elevating legrests. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The records do not show a patient receipt that shows the item was delivered. The records do not indicate if this item was rented or 
purchased.. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for elevating legrests (K0195) 
provided on June 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from December 23, 2022, to 
December 30, 2022. 
 You asked the Plan to pay for the hospital services. You say that the patient was not enrolled in hospice during 
this time. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided from December 23, 2022, to 
December 30, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on January 21, 2023. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the enrollee had two 
claims for same date of service and the transportation timings are different. You also say that you are appealing 
the claim with both claims and submitted medical records. The Plan denied your request. The Plan says that 
this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan denied payment for this service 
on the basis that it is a duplicate of another claim that was already paid. However, the other claim the Plan 
submitted is for a separate ambulance trip and was billed with the appropriate modifiers to distinguish it from 
the service at issue in this case. The Plan did not submit any other evidence of a duplicate claim. Based on this 
information, we decided that Medicare rules for coverage of the ambulance service, basic life support, 
emergency transport and ground mileage have been met. Based on this information, we decided that Medicare 
rules for coverage of the ambulance services and ground mileage  have been met. Therefore, we decided that 
the Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground mileage 
provided on January 21, 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 issue reimbursement for the hearing aids (V5257) purchased on 
January 13, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when purchased from the Plans select hearing aid provider. However, the hearing aids in this 
case were rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5257) purchased on January 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs, Self-administered.  
 
You asked the Plan to pay for the medication. You say that you did not take self-administered drugs. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for drugs, Self-administered.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99201) provided on October 20, 2022. 
 
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 that this service is not payable as it was 
rendered by a chiropractor.  
 
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. Specifically, the Plan has stated that the service provided in this case is not 
payable as it was rendered by a chiropractor. However, the Plan has not forwarded the Evidence of Coverage 
(EOC) contract for the year 2022 in which this service was rendered. We are unable to determine your 
eligibility for coverage of this service provided. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to pay for the office visit (99201) provided on 
October 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87798, 87641) provided on August 18, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87150, 87798, & 87641 is not supported in the medical record. Specifically, code 
87150 is included in code 87500 which was also billed. Codes 87798 & 87641 are included in codes 87150 and 
87801 which were also billed. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87150, 87798, 87641) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210) and to add tooth to existing partial on tooth #4 (D5650) provided on May 2, 2023, 
to May 5, 2023. 
 
You asked the Plan to pay for an extraction and to add tooth to existing partial on tooth #4. You say that this 
should be covered. The Plan denied your request. The Plan says the same tooth cannot be extracted and cannot 
be added to a partial twice. 
 
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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and to add tooth to 
existing partial on tooth #4 (D5650) provided on May 2, 2023, to May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new eye examination and the fundus photography 
provided on November 2, 2022. 
 
You asked the Plan to pay for the new eye examination and the fundus photography. You say that you did not 
know that the provider was out-of-network. You say you need help with your bills. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the new eye examination and the fundus 
photography have not been met. Therefore, we decided that the Plan does not have to pay for the new eye 
examination and the fundus photography provided on November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service January 24, 
2023. 
 You asked the Plan to pay for procedure code 76882. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76882 is bundled into payment for code 93970. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76882 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76882 billed for date of service January 24, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from December 29, 
2022, to January 20, 2023. 
 
You asked the Plan to waive the copayment for SNF care. You say that the enrollee is on a fixed income and 
unable to afford the copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20, a $160 copayment per day for days 21 to 42, and $0 copayment for 
days 43 to 100 for SNF care.  
 
The enrollee has been asked to pay $1,387.50 for SNF care. This amount is less than the standard copayment 
for a SNF stay because the Plan states that your maximum out-of-pocket was met with the processing of this 
claim. This item/service falls within the SNF care benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for SNF care provided from December 29, 2022, to January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on February 28, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that your provider suggested you get inserts after your 
foot surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 28, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 27, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were unaware that there was 2 different 
types of periodontal maintenance and that it would not be covered. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the periodontal maintenance 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 
periodontal maintenance (D4910) provided on April 27, 2023.