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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence product, disposable underpad, large 
(T4541). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are providing the medical 
documentation on why the incontinence pads are needed for ostomy bag changes. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence product, disposable 
underpad, large (T4541).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
29, 2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to 
pay for these services due to the 30-day global period. 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 $120 copayment for emergency care.  
 
The record shows that the emergency room services are not included in the 30-day global period. You have 
been asked to pay a $120 copayment for the emergency room visit. This item/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 copayment for the emergency room visit 
provided on June 29, 2022, to June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on August 09, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you were 
told by the provider that the services would be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for advanced imaging services. 
 
You have been asked to pay a $180 copayment for the computed tomography (CT) scan. This item/service falls 
within the advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the computed tomography (CT) scan provided on August 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with procedure codes 87086, 
87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, and 87798 for date of service March 8, 2023. 
 
You asked the Plan to pay for the laboratory services billed with procedure codes 87086, 87186, 87481, 87500, 
87556, 87563, 87640, 87651, 87653, and 87798. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 21, 2023. Code 87186 was reimbursed on July 13, 2023. Comparison of the 
two claims shows these are exact duplicates. There is no evidence presented to support that the billed 
items/services were provided twice on the same date. Based on this information, we decided that the Medicare 
rules for the laboratory services billed with procedure codes 87086, 87186, 87481, 87500, 87556, 87563, 
87640, 87651, 87653, and 87798 have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services billed with procedure codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 
87651, 87653, and 87798 for date of service March 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 20, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 code 99284 billed for date of service May 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on September 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
September 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring active compression system and 
garment (K1024, K1032). 
 
You asked the Plan to pre-approve the Koya Dayspring system. You say that you believe that the enrollee 
would benefit from the Dayspring home pneumatic compression device. The Plan denied your request. The 
Plan says this device is considered investigational or experimental.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Koya Dayspring system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Koya Dayspring active compression system and garment (K1024, K1032).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 2, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the service was not emergent or pre-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 lab services provided on August 2, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection procedure provided on August 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for injection procedure. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not 
obtained. 
 
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 an injection procedure provided on August 28, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve guided tissue regeneration, natural teeth - resorbable barrier, per 
site (D4266). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not include documentation that shows the treatment is clearly needed. 
 
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 Plan covers the services 
when the services are medically necessary and reasonable. 
 
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 services. Our reviewer says that the 
requested services are medically reasonable or necessary. Our physician reviewer found that a review of the 
documentation indicates that dental implants have been approved for areas #21 and 28 to retain and stabilize a 
complete denture. Placement of the implants required bone grafts at the site. The placement of a resorbable 
barrier over the bone graft is often used to ensure good integration of the graft with the bone by preventing soft 
tissue infiltration between the graft and bone. This treatment is medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve guided tissue regeneration, natural teeth - resorbable barrier, per site (D4266).  
 
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 the dental service (D5212). 
 
You asked the Plan to pre-approve the dental service (D5212). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 June 10, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the dental service (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says a lower partial denture is not covered under the 
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 dental item is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant maintenance procedure (D6080) and the cleaning 
and inspection of removable denture (D9933) for tooth #19 provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to the same dentist who cleaned your 
teeth, and they told you that the services would be covered by the Plan. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the implant maintenance procedure and the 
cleaning and inspection of removable denture are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant maintenance procedure (D6080) and the cleaning and inspection of removable denture (D9933) for 
tooth #19 provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D3120) on July 19, 2023. 
 
You asked the Plan to pay for the dental service (D3120). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the 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 the dental 
service (D3120) on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on June 
16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered because the 
provider is listed as an in-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.  
 
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 the re-cement or re-bond crown (D2920) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D6051 and D6191) on November 7, 
2022. 
 
You asked the Plan to pay for the dental services (D6051 and D6191). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services requested 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 the dental 
services (D6051 and D6191) on November 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services from March 16, 2022, 
to March 31, 2022. 
 
You asked the Plan to pay for SNF services. You say that the original claim was submitted timely. The Plan 
denied your request. The Plan says the claim was not filed 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 corrected claim for SNF services was not filed until July 26, 2023. This means that 
more than one calendar year from the date of service had passed before a corrected claim was filed. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility (SNF) services from March 16, 2022, 
to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D2740) on July 5, 2023. 
 
You asked the Plan to pay for the dental service (D2740). You say that you would like to request 
reconsideration for payment. 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 June 14, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental service (D2740) on July 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) stay after January 9, 
2024. 
 
You asked the Plan to pre-approve the SNF stay. You say that you still need continued antibiotics after January 
9, 2024. The Plan denied your request. The Plan says you will have exhausted your 100-day benefit after 
January 9, 2024. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from August 15, 2023, to 
January 9, 2024. The Plan has covered 100 days of SNF care. 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve the skilled nursing facility (SNF) stay after January 9, 2024.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and intraoral x-rays (D0140, 
D0220) provided on August 28, 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 a limited 
oral evaluation and intraoral x-rays (D0140, D0220) provided on August 28, 2023.