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

 
We decided that the Plan does not have to pay for the hearing aid repair/modification (V5014) provided on 
February 1, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, a hearing aid repair or modification is not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for the hearing aid repair/modification 
(V5014) provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were within the time frame to have a dental 
cleaning and the Plan should cover it. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0210) 
provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on February 17, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on 
February 17, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #18 provided by an out-of-
network provider on February 21, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the Plan should cover the $1,000 for any 
service and not dictate how the annual maximum is used. 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. Also, the correct cost share was applied for the dental service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The total amount billed was $1,572 and the total allowed amount was $718 leaving a difference of $854 
($1,572 billed - $718 allowed). The Plan applied the $50 deductible leaving a balance of $668 ($718 allowed - 
$50 deductible). With the balance of $668 left the total coinsurance applied was $334 ($668 balance x 50% 
coinsurance). The total liability for the crown was $1,238 ($854 difference + $50 deductible + $334 
coinsurance). You have been asked to pay the difference between the out-of-network providers charges and 
the Plans payment. You have also been asked to pay the deductible and the coinsurance for the crown. 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 a crown (D2740) for tooth #18 provided by an out-of-network 
provider on February 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on December 13, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy services. You say that you are an in-network provider. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on 
December 13, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29879 billed for date of service January 26, 
2023.  
 You asked the Plan to pay for procedure code 29879. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29879 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29879 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29879 billed for date of service January 26, 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 
provided on February 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this 
service should have been covered in full. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 8, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for two dental fillings on teeth 15 and 2 
provided on January 13, 2023. 
 
You asked the Plan to waive the cost share for two dental fillings. You say that this should be covered. 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 50% 
coinsurance after $100 deductible for Class 2 Basic Services.  
 
You have been asked to pay $322.50 for two dental fillings. This item/service falls within the Dental Services 
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 cost share for two dental fillings on teeth 15 and 
2 provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341), a core buildup, including any pins when required (D2950), porcelain/ceramic crowns 
(D2740), the surgical placement of implant body: endosteal implants (D6010), custom fabricated abutments-
includes placement (D6057), abutment supported porcelain/ceramic crowns (D6058), and the extractions, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve the dental items/services. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing-four or more teeth per quadrant (D4341), a core buildup, including any pins when 
required (D2950), porcelain/ceramic crowns (D2740), the surgical placement of implant body: endosteal 
implants (D6010), custom fabricated abutments-includes placement (D6057), abutment supported 
porcelain/ceramic crowns (D6058), and the extractions, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the magnetic resonance imaging provided 
on February 27, 2023. 
 
You asked the Plan to reduce the copayment for the magnetic resonance imaging. You say that you feel you 
were charged incorrectly. 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 $250 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for the magnetic resonance imaging. This item/service falls 
within the in-network outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for the magnetic resonance imaging provided on February 27, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 29, 2020, to January 21, 2021. 
 
You asked the Plan to waive the copayment for the hospital stay. You say that the Plan should have covered up 
to 20 days with no copayment. 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 $295 
copayment for inpatient hospital care.  
 
 You have been asked to pay a $295 copayment per day, for days 1 to 4 of the hospital stay. You have been 
asked to pay a total of $1,180 ($295 copayment x 4 days = $1,180). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from December 29, 2020, to 
January 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI provided on January 10, 2023. 
 
You asked the Plan to waive the deductible for the MRI. You say that you had already met your deductible. 
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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also clearly says that you must pay 5% coinsurance after 
meeting the deductible for outpatient diagnostic radiology. You have been asked to pay $188 toward the deductible. The item or service you asked the Plan to waive the 
deductible for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to 
outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual obligation that had not 
been met at the time the MRI was received on January 10, 2023. Therefore, we decided that the Plan does not 
have to waive the deductible for the MRI provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  extracapsular cataract removal to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve  extracapsular cataract removal. You say that you would have to travel over 
50 miles to use an in-network facility with the same participating provider. The Plan denied your request. The 
Plan says this is available in-network. 
 
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  
extracapsular cataract removal to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve the wheelchair van transportation. You say that you are asking the Plan to 
review the submitted records and reconsider coverage. The Plan denied your request. The Plan says this service 
is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation (A0130).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 22, 2022, to November 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that This was an 
emergency, and you should not be expected to pay. 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 $295 
copayment per day for days 1-7 of each inpatient hospital stay. Your contract with the Plan also clearly says you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $295 copayment per day for days 1-3 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
three or for the day you were discharged. You have been asked to pay a total of $885 for the inpatient hospital 
stay ($295 copayment per day x 3 days = $885). 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 
the inpatient hospital stay provided from November 22, 2022, to November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761, and 99072 provided on July 
25, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761, and 99072. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for procedure code 87631. 
 
The rules also say that providers must report services correctly. Providers must report services with the 
appropriate procedure code. We find that procedure code 94761 has a status indicator of T on the Physician Fee 
Schedule. There was another payable service billed on the same date by the same provider. This means that 
procedure code 94761 is not separately payable. We also find that procedure code 99072 has a status indicator 
of B on the Physician Fee Schedule. This means that procedure code 99072 is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87631, 94761, and 
99072 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87631, 
94761, and 99072 provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression that the enrollee 
could have new dentures every 5 years. 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 the Plan paid for a complete upper and lower denture on October 12, 2018, and the benefit for a new set 
of complete dentures would not be until October 12, 2023. Therefore, we decided that the Plan does not have to 
pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on February 16, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260), the bone replacement grafts 
(D4263 and D4264), and the guided tissue regeneration (D4266) for tooth #10, #11, and #12 provided on 
January 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services rendered were common 
procedures to prevent loss of natural teeth and you would like the Plan to cover them. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the osseous surgery, the bone 
replacement grafts, and the guided tissue regeneration 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, 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 
osseous surgery (D4260), the bone replacement grafts (D4263 and D4264), and the guided tissue regeneration 
(D4266) for tooth #10, #11, and #12 provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant maintenance procedures (D6080) provided on 
June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant maintenance procedures (D6080) provided on June 1, 2022.