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

 
We decided that the Plan does not have to pay for crowns for teeth #4, #5, and #10 (D2740) provided on March 
14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 February 23, 2023, when 
you received a crown on teeth #3, #28, and #29. Therefore, we decided that the Plan does not have to pay for 
crowns for teeth #4, #5, and #10 (D2740) provided on March 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on April 4, 2022. 
 
You asked the Plan to pay for the cataract surgery. You say that the cataract surgery was medically necessary. 
The Plan denied your request. The Plan says the claim was submitted incorrectly and untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the cataract surgery was not filed until April 7, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the cataract surgery provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on May 22, 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.  
 
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 (99212) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) for tooth #22 and 
#27, an extraction (D7140) for tooth #3, #4, #5, #6, #8, #9, #10, #11, #12, #17, #18, #20, #21, #22, #23, #24, 
#25, #26, #27, #28, and #29, an extraction requiring removal of bone (D7210) for tooth #3, #4, #5, #6, #11, 
#12, #13, #14, #15, #22, #27, #28, #29, and #30, the removal of tooth roots (D7250) for tooth #18, #19, #20, 
#21, and #25, the removal of torus mandibularis (D7473) for the lower left quadrant, the bone replacement 
graft (D7953) for tooth #5, #13, #22, and #27, and a consultation (D9310) provided on January 25, 2023. You asked the Plan to pay for the dental services. You say that you have provided all the record for the dental 
needs, and they were necessary for denture wear. 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 $2,000 for dental services on January 25, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 25, 2023. Therefore, we decided 
that the Plan does not have to pay for the guided tissue regeneration (D4266) for tooth #22 and #27, an 
extraction (D7140) for tooth #3, #4, #5, #6, #8, #9, #10, #11, #12, #17, #18, #20, #21, #22, #23, #24, #25, #26, 
#27, #28, and #29, an extraction requiring removal of bone (D7210) for tooth #3, #4, #5, #6, #11, #12, #13, 
#14, #15, #22, #27, #28, #29, and #30, the removal of tooth roots (D7250) for tooth #18, #19, #20, #21, and 
#25, the removal of torus mandibularis (D7473) for the lower left quadrant, the bone replacement graft 
(D7953) for tooth #5, #13, #22, and #27, and a consultation (D9310) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, cleaning, crown, and crown 
restoration services () provided on April 24, 2023, to May 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation, cleaning, crown, and crown restoration services () provided on April 24, 
2023, to May 16, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on May 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 22, 2023. Therefore, 
we decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on May 22, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment and occlusal adjustment (D9110, D9951) 
provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 palliative 
treatment and occlusal adjustment (D9110, D9951) provided on May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel (87641, 
87801, 87500, 87798, 87651, and 87640) provided on April 7, 2023. 
 
You asked the Plan to pay for the wound PCR panel. 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. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel 
(87641, 87801, 87500, 87798, 87651, and 87640) provided on April 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (A9270, A6235, A5120, G0299) 
provided from April 3, 2023, to April 28, 2023. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as despite 
multiple requests to the requesting provider, records documenting home health care services rendered and a 
plan of care ordered or certified by your physician or other allowed practitioner were not provided. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the home health services have been 
met. medical records. Therefore, we decided that the Plan does not have to pay for home health services 
(A9270, A6235, A5120, G0299) provided from April 3, 2023, to April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on February 28, 2022, to 
November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the claim was not 
received timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until April 4, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a cleaning (D1110) provided on February 28, 2022, to November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on April 11, 2023. 
 
You asked the Plan to pay for core buildup. You say that you called for a list of in-network providers. The Plan 
denied your request. The Plan says this service is not a covered expense 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, including 
any pins when required (D2950) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-ray, and 
cleaning (D0150, D0210, D1110) provided on April 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-
ray, and cleaning (D0150, D0210, D1110) provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography and eye exam provided on April 28, 
2023, by an OON provider.  
 
You asked the Plan to pay for the fundus photography and eye exam. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 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 
item/service 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 fundus photography and eye exam provided on 
April 28, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation treatment services provided 
on April 25, 2023, to April 27, 2023. 
 
You asked the Plan to waive the coinsurance for the radiation treatment services. You say that you should only 
be charged for a specialist office visit and an endoscopy procedure. 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 20% 
coinsurance for radiation therapy provided at an outpatient hospital. 
 
 
 You have been asked to pay $115.27, which is 20% coinsurance for the radiation treatment provided on April 
25, 2023 ($576.35 allowed amount x 20% = $115.27). You have also been asked to pay $72.23, which is 20% 
coinsurance of the allowed amount for the radiation treatment device provided on April 27, 2023 ($361.15 
allowed amount x 20% = $72.23).  You have been asked to pay a total of $187.50 ($115.27 coinsurance + 
$72.23 coinsurance = $187.50). These items/services fall within the 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 waive the coinsurance for the 
radiation treatment services provided on April 25, 2023, to April 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric service to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve psychiatric service. You say that the services should be covered. 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 
psychiatric service 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 pre-approve skin substitute grafts. 
 
You asked the Plan to pre-approve skin substitute grafts. You say that it is medically necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve skin substitute grafts. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the literature on this specific product is not yet sufficient due to only low quality, 
smaller studies being available to support this request for this enrollees condition. Other approved and 
supported skin substitute products may be more appropriate. Therefore, this request for matrion will be 
considered not medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute grafts have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute grafts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you would like to continue seeing this 
provider. The Plan denied your request. The Plan says there are network providers that can provide these 
services. 
 
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 
the office visit to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines. 
The Plan says that the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips. 
 
You asked the Plan to pre-approve the requested test strips. The Plan denied your request. The Plan says only 
the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the requested test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test 
strips.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne Liquid CDx (F1LCDx) (0239U) provided on March 
24, 2022. 
 
You asked the Plan to pay for F1LCDx testing. You say that this test was medically necessary. The Plan denied 
your request. The Plan says that this claim is denied. 
 
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 not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for FoundationOne Liquid CDx (F1LCDx) 
(0239U) provided on March 24, 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.