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

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), and 
intraoral x-rays (D0220, D0230) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not told at any point that these 
services would not be covered. You say that you cannot afford to pay this bill on your limited income. The Plan 
denied your request. The Plan says your benefit for the periodontal evaluation has already been exhausted. The 
Plan also says that the intraoral x-rays are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the periodontal exam was exhausted on date of service June 10, 2023. Additionally, the 
intraoral x-rays are not listed as covered services. Therefore, we decided that the Plan does not have to pay for 
the comprehensive periodontal evaluation (D0180), and intraoral x-rays (D0220, D0230) provided on July 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) 
provided on August 28, 2023, and August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the rejected claims to be 
reconsidered for coverage. The Plan denied your request. The Plan says your benefits for the services have 
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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray 
(D0220) was exhausted on date of service August 29, 2023. The record shows your benefit for the additional 
intraoral periapical x-ray (D0230) was exhausted on date of service August 29, 2023, because you received a 
first intraoral periapical x-ray (D0220) which was covered by the Plan. The record also shows your full mouth 
or panoramic x-rays benefit for the panoramic x-ray (D0330) was exhausted on date of service February 3, 
2023, when you received a comprehensive series of intraoral x-rays (D0210). Therefore, we decided that the 
Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-
ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on August 
28, 2023, and August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 24, 2023, to August 
28, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
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 chiropractic services provided on August 24, 2023, to August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), a limited oral 
evaluation (D0140), the intraoral radiographic images (D0220 and D0230), a crown (D2740) for tooth #4, a 
partial upper denture (D5820), and to pay for a cleaning (D1110), a partial upper denture (D5213), and a bone 
replacement graft (D7953) provided on May 2, 2023, May 5, 2023, May 25, 2023, and June 6, 2023. 
 You asked the Plan to pay more for the dental services. You say that you were never informed that you would 
need oral surgery and the partial plate did not fit in your mouth correctly. 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 $27 for dental services on April 13, 2023. On May 2, 2023, the Plan paid $331.50 for 
dental services. On May 16, 2023, the Plan paid $623 for dental services. On May 25, 2023, the Plan paid $18 
for dental services. For the year of 2023 the Plan paid $1,000 ($27 paid + $331.50 paid + $623 paid + $18 paid) 
for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the 
date of service of May 25, 2023. Therefore, we decided that the Plan does not have to pay more for a periodic 
oral evaluation (D0120), a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and 
D0230), a crown (D2740) for tooth #4, a partial upper denture (D5820), and to pay for a cleaning (D1110), a 
partial upper denture (D5213), and a bone replacement graft (D7953) provided on May 2, 2023, May 5, 2023, 
May 25, 2023, and June 6, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions (64450, 77003, 64491, 64490). 
 
You asked the Plan to pre-approve facet joint interventions. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet certain criteria.  
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 facet joint interventions. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has cervicalgia and underwent a single diagnostic block in November 2023 that resulted in minimal 
relief. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions (64450, 77003, 64491, 64490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), and panoramic 
radiographic image (D0330) provided on August 30, 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 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 July 17, 2023. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), and panoramic 
radiographic image (D0330) provided on August 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has sacral osteomyelitis due to decubitus ulcers and is being treated with two 
intravenous antibiotics for a total of six weeks. The enrollee will likely require inpatient level care that will 
meet or exceed 25 additional days. The enrollee's care provider has advocated for transfer to the LTACH due to 
the extensive care required for the enrollee's wounds and duration of the anticipated treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 1, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documentation and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services and the ER visit 
provided on August 29, 2023. 
 
You asked the Plan to waive the copayments for the ambulance services and the ER visit. You say that you 
should be held harmless for the copayments. 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 $225  
 copayment for ambulance services. The Plan contract also says that you must pay a $95 copayment for an ER 
visit. 
 
You have been asked to pay a $225 copayment for the ambulance services. This service falls within the 
ambulance services benefit category. You have also been asked to pay a $95 copayment for the ER visit. This 
service falls within the emergency 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 copayments 
for the ambulance services and the ER visit provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic images 
(D0230), and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on July 
27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you received a bill for $568 but the services 
were just for a cleaning. The Plan denied your request. The Plan says your benefit for the intraoral - periapical 
each additional radiographic image(s) has already been exhausted. The Plan also says that D0350 service is not 
covered 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, certain limitations apply. The record 
shows your benefit for the intraoral - periapical each additional radiographic images was exhausted on date of 
service July 27, 2023. You received the allowed frequency of one intraoral-periapical x-ray on the appealed 
claim. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic images (D0230) provided on July 27, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D oral/facial photographic image 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), and core buildup, including any pins when 
required (D2950) provided on July 14, 2023, and July 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had multiple follow-ups for services that 
required x-rays. The Plan denied your request. The Plan says your benefit for the intraoral x-rays has already 
been exhausted. The Plan also says there is no coverage for D2950 core buildup, including any pins when 
required. 
 
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 intraoral x-rays was exhausted on date of service July 21, 2023. You received two 
D0230 intraoral  periapical each additional radiographic image and one D0220 intraoral - periapical first 
radiographic image on July 14, 2023. You received one D0220 intraoral - periapical first radiographic image 
and two D0230 intraoral - periapical each additional radiographic image on 07/21/2023 which exhausted this 
benefit.  Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic 
image (D0220), intraoral - periapical additional radiographic image (D0230) provided on July 14, 2023, and 
July 21, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup, including any pins 
when required 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 July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 23, 2023, to 
March 25, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and codes were necessary and are supported as billed. The Plan denied your request. The Plan says the 
diagnoses are not supported as billed; therefore, the DRG is changed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute respiratory failure with hypoxia (J96.01). 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 pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis code is not supported in the records provided. Our 
physician reviewer found the enrollee presented with shortness of breath and mild hypoxia. There was no 
evidence of pneumonia, viral illness or pulmonary embolism (PE). The enrollee was treated for a chronic 
obstructive pulmonary disease (COPD) exacerbation. There was no evidence of respiratory failure. As such, the 
billing of J96.01 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 23, 2023, to March 25, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 30, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consult (D9310) and cone beam CT (D0364) provided on 
October 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 a consult 
(D9310) and cone beam CT (D0364) provided on October 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the panoramic 
radiographic image (D0330), and a cleaning (D1110) provided by an out-of-network provider on August 23, 
2023. 
  You asked the Plan to pay for the dental services. You say that you had received an approved authorization and 
you thought once you had an approval you were free to see the out-of-network provider. 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. Also, it was verified that the approved authorization ended on May 6, 2023. 
 
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 periodic oral evaluation (D0120), the panoramic radiographic image (D0330), and a cleaning 
(D1110) provided by an out-of-network provider on August 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 02, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on August 02, 2023.