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

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) provided on June 1, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the dental service 
provided 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 service provided was exhausted on date of service June 1, 2023.  
  
 
 
 
 
Specifically, the Plans contract states that one intraoral periapical x-ray is covered per year. On this day, you 
received two intraoral periapical x-rays, of which one x-ray was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the intraoral-periapical additional radiographic image (D0230) provided on June 1, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit (99284) provided on March 29, 2023, to 
March 30, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit (99284) provided on March 29, 2023, to March 30, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for December 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99233 is not supported. 
 
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, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our physician 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 these services. Our reviewer says that procedure code 
99233 is not supported. Our reviewer found the enrollee was hospitalized with pneumonia and sepsis. The 
submitted records do not support a detailed interval history or medical decision making of high complexity was 
performed for December 16, 2022. Code 99233 is therefore not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99233 billed for December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 83550 rendered on March 24, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no specific rationale for the additional units.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the additional units were 
rendered, but the documentation does not specify why the additional units were medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 83550 rendered on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) for 
tooth #2, #4, #5, #6, #11, #12, #13, #14, #15, #18, #20, #21, #22, #26, #27, #28, #29, and #31 and the gingival 
irrigation (D4921) for 4 quadrants provided on June 15, 2023, to June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary 
due to advanced gum disease treatment that was needed. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the localized delivery of antimicrobial agents and the 
gingival irrigation 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 the 
localized delivery of antimicrobial agents (D4381) for tooth #2, #4, #5, #6, #11, #12, #13, #14, #15, #18, #20, 
#21, #22, #26, #27, #28, #29, and #31 and the gingival irrigation (D4921) for 4 quadrants provided on June 15, 
2023, to June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete upper denture (D5750) and a reline 
of a complete lower denture (D5751) provided by an out-of-network provider on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentures were disconnecting from your 
mouth, and you are confused as to why your case was denied because the Plan pays for preventative 
procedures. 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 reline of a complete upper denture (D5750) and a reline of a complete lower denture (D5751) 
provided by an out-of-network provider on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment-includes placement for 
tooth number 5 (D6057) and an abutment supported porcelain/ceramic crown for tooth number 5 (D6058). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service June 15, 2023.  
  
 
 
Specifically, the Plans contract states that two dental implants are covered per year. You previously received 
dental implants for teeth number 4 and 6 on June 15, 2023, that were paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for these items. Therefore, we decided that the Plan does not have to pre-
approve a custom fabricated abutment-includes placement for tooth number 5 (D6057) and an abutment 
supported porcelain/ceramic crown for tooth number 5 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided on June 20, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that there is no 
documentation explaining frequency limitations. You also say that you have a $1000 dental benefit that covers 
oral examinations and x-rays, and since this is your first dental visit for 2023 with an in-network provider, you 
assumed the total charges would be covered. The Plan denied your request. The Plan says your benefit for the 
intraoral - complete series of radiographic images  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 service was exhausted on date of service August 30, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) 
provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), 
licensed logo (V2799), photochromatic lenses (V2744), anti-reflective coating (V2750), variable sphericity 
lenses (V2499), scratch resistant coating (V2760), and ultra-violet (UV) lenses (V2755) provided on May 13, 
2023. 
 
You asked the Plan to pay for progressive lenses (V2781), polycarbonate lenses (V2784), licensed logo 
(V2799), photochromatic lenses (V2744), anti-reflective coating (V2750), variable sphericity lenses (V2499), 
scratch resistant coating (V2760), and ultra-violet (UV) lenses (V2755). You say that you do not believe this 
was anything ordinary or run-of-the-mill, so you do not believe the benefit amount applies to your situation. 
You also say you think the need to have new lenses is related to your neurological condition. The Plan denied 
your request. The Plan says the maximum benefit is exceeded. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $150 allowance for non-Medicare covered eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $150 allowance for non-Medicare 
covered eyewear every year. The Plan rules also say you are responsible for all costs over and above the 
allowance amount. Based on this information, we decided that the Plan's rules for coverage of progressive 
lenses (V2781), polycarbonate lenses (V2784), licensed logo (V2799), photochromatic lenses (V2744), anti-
reflective coating (V2750), variable sphericity lenses (V2499), scratch resistant coating (V2760), and ultra-
violet (UV) lenses (V2755) have not been met. Therefore, we decided that the Plan does not have to pay for 
progressive lenses (V2781), polycarbonate lenses (V2784), licensed logo (V2799), photochromatic lenses 
(V2744), anti-reflective coating (V2750), variable sphericity lenses (V2499), scratch resistant coating (V2760), 
and ultra-violet (UV) lenses (V2755) provided on May 13, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the room and board services provided from January 1, 2023, 
to January 31, 2023. 
 You asked the Plan to pay for the room and board services. You say that the services are a covered benefit. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the room and board services provided from January 1, 2023, 
to January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your
request. The Plan says the enrollee does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found The complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical management of osteomyelitis of the lower extremity. Medical problems are stable.
There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care.

There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 10, 
2023, to March 20, 2023. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee no longer needed skilled services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 10, 2023, to March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), frames (V2020) and 
photochromatic tint (V2744) provided from April 6, 2023, to May 4, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), frames (V2020) and photochromatic tint (V2744). 
You say that you were told by the Plan representative that you were covered. The Plan denied your request. 
The Plan says the provider who rendered services is not contracted and did not preauthorize. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you receive prior authorization before obtaining your glasses for 
out-of-network covered services. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover up to $850 per year toward the 
purchase of eyeglasses (frames and lenses). The Plan rules also say that authorization rules apply for out-of-
network covered services. There is no evidence that prior authorization was obtained before the purchase of the 
eyeglasses. Based on this information, we decided that the Plan's rules for coverage of progressive lenses 
(V2781), frames (V2020) and photochromatic tint (V2744) have not been met. Therefore, we decided that the 
Plan does not have to pay for progressive lenses (V2781), frames (V2020) and photochromatic tint (V2744) 
provided from April 6, 2023, to May 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency services provided on April 
25, 2023. 
 
You asked the Plan to waive the copayment for the emergency service. You say that it was a medical 
emergency that you were taken to the nearest facility. 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 $90 
copayment for each emergency care visit.  
 
  You have been asked to pay a $90 copayment for the emergency service. 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 services 
provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on January 24, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004). You say that you say the 
Plan assured you that as long as you select an in-network provider it would be 100% 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 $50 
copayment for a specialist office visit. 
 
You have been asked to pay a $50 copayment for a medical eye examination (92004). This item/service falls 
within the a specialist office visit 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 a 
medical eye examination (92004) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction of an erupted tooth (D7210) for tooth 
number 30 provided on June 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you called the Plan and were informed 
that this provider was in-network and given contact details for this provider. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for an extraction of an erupted tooth (D7210) for 
tooth number 30 provided on June 9, 2023.