Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Etonogestrel (contraceptive) implant system (J7307) 
provided on December 7, 2022. 
 
You asked the Plan to pay for the Etonogestrel (contraceptive) implant system. You say that this denial is 
causing you financial impact. You also say that you have tried alternative birth control, but it causes you to 
have headaches and nausea. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.   
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
the Etonogestrel (contraceptive) implant system (J7307) provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service February 17, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service February 17, 2022, billed 
with code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has paid the full $2,000 dental benefit for services provided on August 15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought your dentures would be 
covered in full by your insurance. 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 August 15, 2022. 
Therefore, we decided that the Plan has paid the full $2,000 dental benefit for services provided on August 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic services provided on 
December 19, 2022. 
 
You asked the Plan to waive the copayment for the outpatient clinic services. You say that you should only 
have a $40 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 $250 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the outpatient clinic services. This item/service falls within 
the in-network outpatient hospital 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. The records show the services were provided by an outpatient hospital. 
However, since the allowed amount is less than the standard copayment, you only owe $134.95. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient clinic services provided on 
December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of any limits, and you do 
not have the money to pay for the billed service. 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. This benefit includes the 
requested limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan year 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you receive covered limited oral evaluation - problem focused (D0140) on January 13, 2022. Therefore, 
this benefit was exhausted as of December 22, 2022. Therefore, we decided that the Plan does not have to pay 
for limited oral evaluation - problem focused (D0140) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), each additional radiographic image (D0230), bitewings 
- four radiographic images (D0274) and periodontal maintenance (D4910) provided on June 28, 2022. 
 
 
 You asked the Plan to pay for the dental services represented by codes D0120, D0220, D0230, D0274 and 
D4910. You say that you believe this was incorrectly denied. Attached documentation for your 2022 HMO 
plan shows network and preventive dental is covered. The Plan denied your request. The Plan says the dental 
services represented by dental codes D0120, D0274 and D4910 were received from an out-of-network 
provider. The Plan also say the dental codes represented by D0220 and D0230 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. 
 
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 or the services are not covered by 
the Plan. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established 
patient (D0120), intraoral - periapical first radiographic image (D0220), each additional radiographic image 
(D0230), bitewings - four radiographic images (D0274), and periodontal maintenance (D4910) provided on 
June 28, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) provided on 
January 11, 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 x-ray exam of the cervical spine (72040) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180) provided on December 15, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you are asking the 
insurance to cover the procedure that was performed. You also say that this is a covered benefit. The Plan 
denied your request. The Plan says this service is not covered under 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 a 
comprehensive periodontal evaluation - new or established patient (D0180) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), and intraoral - 
periapical each additional radiographic image (D0230) provided on February 9, 2023, 
 
You asked the Plan to pay for the bitewings and intraoral - periapical each additional radiographic image. You 
say that you are appealing to go back to the previous $0 copayment for this benefit. The Plan denied your 
request. The Plan says codes D0274 and D0230 are not listed and therefore are not covered 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 bitewings 
- four radiographic images (D0274), and intraoral - periapical each additional radiographic image (D0230) 
provided on February 9, 2023,
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided on August 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not aware the service was not covered, 
also you say that you were not told that coverage could be added to your plan for a small fee. Therefore, you 
feel the services should be paid for by your insurance. 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. Crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) are not covered under the Plans dental 
services. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 and D2950 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
- porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on August 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided on January 24, 2023. 
 
You asked the Plan to pay for D7953. You say that these services should be covered. The Plan denied your 
request. The Plan says this service is not a covered benefit. 
 
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 a bone 
replacement graft for ridge preservation (D7953) provided on January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital admission provided on October 30, 2022, to 
November 5, 2022. 
 
You asked the Plan to pay for an inpatient hospital admission. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
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. Plans must provide reimbursement for all plan-covered medically necessary 
services received from non-contracted providers without prior authorization requirements. Therefore, we 
decided that the Plan has to pay for an inpatient hospital admission provided on October 30, 2022, to 
November 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment, by report (D5862), and surgical 
placement of implant body: endosteal implant tooth #s 22 and 27 (D6010). 
 
You asked the Plan to pre-approve the precision attachment, by report and surgical placement of implant body. 
You say that you need implants for the dentures to stay in place and to speak and eat. You also say that the 
dentures you have  now are falling out, and the implants would help keep the dentures in place. The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
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 pre-approve 
precision attachment, by report (D5862), and surgical placement of implant body: endosteal implant tooth #s 22 
and 27 (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 4, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral hygiene instructions (D1330), inhalation of nitrous 
oxide/anxiolysis, analgesia (D9230), drugs or medicaments dispensed in the office for home use (D9630), and 
the application of a desensitizing medicament (D9910). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under your 
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 requested services are not among 
those covered under this benefit. Additionally, the application of a desensitizing medicament is a covered 
service under the Plans contract but a report indicating the medical necessity of the service should be included; 
however, this information was not provided. Therefore, we decided that the Plan does not have to pre-approve 
oral hygiene instructions (D1330), inhalation of nitrous oxide/anxiolysis, analgesia (D9230), drugs or 
medicaments dispensed in the office for home use (D9630), and the application of a desensitizing medicament 
(D9910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and infiltration of a 
sustained release therapeutic drug, per quadrant (D9613). 
 
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, 
unassigned dentist are not covered by your supplemental benefits. Additionally, biologic materials to aid in soft 
and osseous tissue regeneration and infiltration of a sustained release therapeutic drug are not covered. Also, a 
bone replacement graft is only covered in conjunction with the surgical placement of an implant.   
 
 
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 items/services from an out-of-network, unassigned dental provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental items/services are not covered under this benefit 
when received from an out-of-network, unassigned dental provider. Additionally, biologic materials to aid in 
soft and osseous tissue regeneration and the infiltration of a sustained release therapeutic drug are not covered. 
Also, a bone replacement graft for ridge preservation is only covered in conjunction with the surgical 
placement of an implant. The record does not show that an implant has been included in this request. Therefore, 
we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and infiltration of a 
sustained release therapeutic drug, per quadrant (D9613).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5298). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
items. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though these items may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids 
(V5298).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you have been using the meter 
for years and this is the first time it has been denied. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.