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

 
We decided that the Plan does not have to pay more for dental services provided on July 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee should not be liable for the 
received services. 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 item or service but is limited to you pay 100% of charges beyond the $2,000 annual allowance or if 
you exceed a service limit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $49 for services on April 14, 2022, $512 for services on May 2, 2022, $204 for services on 
May 3, 2022, and $1,235 for services on July 6, 2022 ($49 + $512 + $204 + $1,235 = $2,000). After the annual 
maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan 
does not have to pay more for dental services provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 December 14, 2022.
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 30, 2022, to January 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were charged for a 
semi-private room that you did not receive. 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 $290 
copayment per day, for days 1 to 7 and a $0 copayment per day for days 8 to 90 for Medicare-covered hospital 
stays.  
 You have been asked to pay a $290 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,160 ($290 copayment x 4 days = $1,160). 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 30, 2022, to 
January 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service January 4, 
2023. 
 
You asked the Plan to pay for procedure code 77065. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 77065 is bundled into payment for code 77066. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77065 
is a column II code to column I code 77066 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 77065 billed for date of service January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on July 29, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not denied the service, so you do not 
understand why insurance did not pay out. The Plan denied your request. The Plan says this service is 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. Comprehensive periodontal 
evaluation - new or established patient (D0180) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive 
periodontal evaluation - new or established patient (D0180) provided on July 29, 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 January 10, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. 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 
10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on January 
10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay for this, because you 
were not told that the billed service would not 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. This benefit includes the 
requested panoramic radiographic image but is limited to full mouth or panoramic x-rays are covered at the 
frequency of 1 procedure code every 5 calendar years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered intraoral - complete series of radiographic images (D0210) on January 10, 2023.  
Therefore, this benefit was exhausted as January 10, 2023. Although these are two different services, they fall 
within the same category in your Evidence of Coverage and are subject to the same frequency limitations.  
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 30, 2022, billed 
with code 71046. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was coded with an invalid diagnosis or 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that manifestation diagnosis codes are never 
permitted to be used as first listed or principal diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with primary diagnosis 
I25.83, which is a manifestation code. Therefore, we decided that the Plan does not have to pay for imaging 
services provided on November 30, 2022, billed with code 71046.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, & 87798 billed for date of 
service October 18, 2022. 
 You asked the Plan to pay for procedure codes 87481, 87653, & 87798. You say that these services were 
medically necessary. The Plan denied your request. The Plan says payment for codes 87481, 87653, & 87798 is 
bundled into payment for codes 87150 and 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87653, & 87798 are column II codes to column I codes 87150 and 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, 
& 87798 billed for date of service October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 3, 
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 oral 
hygiene instructions (D1330) provided on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide services provided on April 20, 2022 to 
July 31, 2022. 
 
You asked the Plan to pay for the aide services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services provided were custodial in nature and are not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health aide services provided 
on April 20, 2022 to July 31, 2022.
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 October 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
suffering a medical emergency but once the ambulance arrived, they were able to stabilize you. 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 October 8, 2022. 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 October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics help relieve the pain and you need 
replacements. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Contour Next One meter and test strips. 
 
You asked the Plan to pre-approve Contour Next One meter and test strips. You say that you are appealing the 
denied items. The Plan denied your request. The Plan says that the requested diabetic test strips and meter are a 
non-preferred product. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred as long the MA plan discloses DME coverage limitation with the EOC and ANOC.  
 
We looked at your contract with the Plan. We did not see any evidence that the Plan disclosed the DME 
coverage limitation of preferred brands in their EOC. The Plan contract does not clearly say there is a list of 
preferred brands or state that enrollees must use a preferred brand. This means that the Plan did not follow 
Medicare rules for disclosure of using preferred brands for the blood glucose monitors and test strips. 
Therefore, we decided that the Plan has to pre-approve Contour Next One meter and test strips. 
 
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 pay for the bone replacement graft (D7953) for tooth #8 provided on 
December 6, 2022. 
 
You asked the Plan to pay for the dental service. You say that the procedure was prescribed by your dentist, 
and you clearly needed a replacement of your front tooth. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the bone replacement graft is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) for tooth #8 provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided 
on February 8, 2023. 
 
You asked the Plan to pay for dental services. You say that the services should be covered under your 
insurance plan. 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. Periodontal scaling and root 
planing - four or more teeth per quadrant (D4341) and periodontal scaling and root planing - one to three teeth 
per quadrant (D4342) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4341 and D4342 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) and periodontal scaling and root 
planing - one to three teeth per quadrant (D4342) provided on February 8, 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 July 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
refused this service is because all you had done was to see if you had a concussion. You also say that the 
ambulance crew only checked your blood pressure. 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 July 7, 2022. 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 July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557) 
provided on February 2, 2023. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $45 
copayment for each Medicare-covered diagnostic hearing exam.  
 
You have been asked to pay a $45 copayment for the Medicare-covered diagnostic hearing exam provided. 
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 comprehensive hearing test 
(92557) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid examination and selection; binaural (92591) 
provided on May 10, 2022. 
 
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 the service is not payable as it was not 
rendered by the Plan's select hearing aid provider. 
 
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, the Plans contract states that coverage is provided for 
hearing aids and hearing exams only when provided through the Plans select hearing aid vendor. However, the 
service in this case was not rendered by the Plans select hearing aid provider. Therefore, we decided that the 
Plan does not have to pay for the hearing aid examination and selection; binaural (92591) provided on May 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2740) and core buildup (D2950) for 
tooth #4, #5, and #6 provided on January 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dental services should be covered 
because it was a medical necessity to get them done. 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 On January 9, 2023, the Plan paid $500 for the dental services; therefore, your benefit for the year of 
2023 was exhausted on the date of service of January 9, 2023. Therefore, we decided that the Plan does not 
have to pay more for the crowns (D2740) and core buildup (D2950) for tooth #4, #5, and #6 provided on 
January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on December 6, 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 06, 2022, and 
August 22, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L1930) and (L2820). 
 
You asked the Plan to pre-approve the foot orthotics. You say that the orthotics/brace were not made just for 
general comfort of the patient or for cosmetic reasons. These items are medically necessary to help control and 
eliminate painful symptoms. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L1930) and 
(L2820).