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

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on August 10, 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 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
comprehensive series of radiographic images (D0210) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance procedures when prostheses are 
removed and reinserted (D6080) and repair broken complete denture base, mandibular (D5511) provided on 
June 2, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant maintenance procedures when prostheses are removed and reinserted (D6080) and repair broken complete 
denture base, mandibular (D5511) provided on June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
image (D0220), and the pulp vitality tests (D0460) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were in serious pain, and you needed to see 
the endodontist right away. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation and the intraoral radiographic image has already been exhausted. Also, the pulp vitality tests are not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 21, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and the pulp vitality tests (D0460) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on August 8, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service February 9, 2023.  
  
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images or related 
service is covered every three years. You previously received a panoramic x-ray (D0330) on February 9, 2023, 
less than three years prior, which was paid for by the Plan. According to the Plans contract, this is a related 
service to the service at issue. Therefore, you have exhausted the allowable benefit for the service provided in 
this case. Therefore, we decided that the Plan does not have to pay for the intraoral-comprehensive series of 
radiographic images (D0210) provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the application of mechanical traction, and 
the application of electrical stimulation provided on September 18, 2023, to September 22, 2023. 
  
You asked the Plan to pay for the office visit, the application of mechanical traction, and the application of 
electrical stimulation. You say that you went to the chiropractor for ongoing pain and that you would have not 
gone if you knew the plan did not cover the expenses. The Plan denied your request. The Plan says the services 
are not covered benefits. 
 
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, the application of mechanical traction, and the application of 
electrical stimulation provided on September 18, 2023, to September 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on September 28, 2023. 
 
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 claim does not meet coding standards. 
 
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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 96401 is not supported. The 
record shows Prolia was administered. This is not a chemotherapy drug; there is a more appropriate administration code. 
 
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 procedure code 96401 rendered on September 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for root canal (D3330) provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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 $1,5000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for root canal (D3330) provided on April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Mis 2 reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre Mis 2 reader. You say that the enrollee is having a 
difficult time with finger sticks as he is getting older. You also asked to provide the CGM to help him to 
continue to manage his blood sugars. The Plan denied your request. The Plan says a CGM is covered under 
Medicare only if a enrollee with diabetes is on insulin or has documentation of very low blood sugars that has  
occurred several times. 
 
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 Mis 2 reader have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre Mis 2 reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant (D6010 x2) and core buildup (D2950 x2). 
 
You asked the Plan to pre-approve the surgical placement of implant body and core buildup. You say that you 
are requesting reconsideration for the denial of these services. The Plan denied your request. The Plan says 
your enhanced dental benefit limits have been met for the calendar year 2023. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on December 15, 2023 when the Plan 
authorized D6010 x2 and D2950 x3. The requested services are also not eligible for coverage under the 
medical benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of 
implant body: endosteal implant (D6010 x2) and core buildup (D2950 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 24, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you have periodontal disease. You also say that 
you have to have cleanings done four times a 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair (PWC) repairs. 
 
You asked the Plan to pre-approve PWC repairs. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the cost to replace the current wheelchair is less than the estimated repairs. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess.   
 
We looked at the file and Medicare rules. The file shows that the repair costs show to be $7,462.92. The file 
shows there have been no previous repairs made. The total cost for replacement of this equipment is $849. This 
means that the expense for repairs to this item exceed the estimated expense of purchasing another item for the 
remaining period of medical need, and no payment can be made for the repair costs requested. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair (PWC) repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extra spine chiropractic manipulative treatment provided 
by a chiropractor on June 26, 2023. 
 
You asked the Plan to pay for the extra spine chiropractic manipulative treatment. You say that the chiropractor 
adjusted your spine as well as your neck areas and not just your neck. 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 extra spine chiropractic manipulative treatment provided by a chiropractor 
on June 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on July 11, 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 July 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on June 30, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 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 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 an emergency department visit (procedure 99284). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found a medically appropriate physical exam was performed; However, the records do not support a moderate 
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 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on June 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on April 15, 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 treatment for this seroma 
and the medical records do not support this level of complexity for medical 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management of an individual (99397) provided on August 8, 2023. 
 
You asked the Plan to pay for the physician service. You say that the service you received in January 2023 was 
not an annual preventive exam. You say that the one at issue in this case should be covered. The Plan denied 
your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
The file shows that the Plan previously paid for this service previously in 2023. Therefore, we decided that the 
Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management of 
an individual (99397) provided on August 8, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 tests provided on October 17, 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 October 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 16, 2023. 
 
You asked the Plan to pay for the ambulance service. You say that the medical personnel advised that you did 
not need to go to the hospital. You say that they advised to continue taking your medications. You also say that 
you feel you should not be responsible for the $165 bill that you received. The Plan denied your request. The 
Plan says the ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
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 June 16, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Additionally, the file shows that the refusal report was signed. Therefore, we decided that the Plan does not 
have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the pontics (D6245 x2) and to pay for the retainer 
crowns (D6740 x2) provided on September 7, 2023.  
 
You asked the Plan to pay more for the pontics and to pay for the retainer crowns. You say that you were never 
told ahead of time from the office that your insurance is not covering this. The Plan denied your request. The 
Plan says your benefit for the requested items or 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 annual maximum dental benefit was exhausted on date of service September 7, 2023. Therefore, 
we decided that the Plan does not have to pay more for the pontics (D6245 x2) and to pay for the retainer 
crowns (D6740 x2) provided on September 7, 2023.