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

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 4) provided on March 28, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are 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 services provided are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210 x 4) provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on July 7, 
2023. 
 
You asked the Plan to pay for the CGM. 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 the rendering provider is 
not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth-completely bony (D7240) 
provided on June 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of an 
impacted tooth-completely bony (D7240) provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (92014, 92083, 92133) provided on 
June 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ophthalmology services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the service was not pre-authorized or emergent. 
 
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 ophthalmology services (92014, 92083, 92133) 
provided on June 14, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crowns fused to noble metal for teeth# 26, 27 
(D2752). 
 
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 the enrollee's 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 Plan's 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 enrollee's benefit for the requested items has already been exhausted. Specifically, the Plan's 
contract states that two dental crowns are covered per year. The Plan previously approved dental crowns for 
teeth# 6 and 11. Therefore, the enrollee has exhausted the allowable benefit for the dental items requested in 
this case. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns fused to noble 
metal for teeth# 26, 27 (D2752).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 x 5 billed for date of service May 26, 
2023.  
 
You asked the Plan to pay for procedure code 88341 x 5. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 18 total units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341 x 5 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
88341 x 5 billed for date of service May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy, anterior tooth (D3310), 
endodontic therapy, premolar tooth (D3320), and endodontic therapy, anterior tooth (D3330). 
 
You asked the Plan to pre-approve the dental services. You say that this is the doctor you were referred to. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve the endodontic therapy, anterior tooth 
(D3310), endodontic therapy, premolar tooth (D3320), and endodontic therapy, anterior tooth (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary to help your leg swelling. The Plan denied your request. The Plan says the stockings are not covered 
by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the second opinion with an out-of-network (OON) provider provided 
on July 14, 2023. 
 
You asked the Plan to pay for the second opinion with an OON provider. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the provider is OON. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the second opinion with an OON provider by a contract provider. The file does not show 
that the Plan provided notice that the second opinion with an OON provider would not be covered. Under 
Medicare rules, this means the second opinion with an OON provider is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the second opinion with an out-of-network (OON) provider 
provided on July 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan (93970) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a duplex scan to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a duplex scan (93970) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) and the periodic oral evaluation 
(D0120) provided on September 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that your benefit for the services 
provided has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, there has been no evidence submitted by the Plan that demonstrates your 
benefit for the services provided was previously exhausted. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the periodontal 
maintenance (D4910) and the periodic oral evaluation (D0120) provided on September 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health stay provided 
from August 29, 2023, to September 5, 2023. 
 
You asked the Plan to waive the copayment for the inpatient mental health stay. You say that you are appealing 
the cost share applied to this claim. 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 $300 
copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for inpatient services in a 
psychiatric hospital. 
 You have been asked to pay $1,500, which is a $300 copayment per day for the first five days of the inpatient 
mental health stay ($300 copayment x 5 days = $1,500). You have not been charged beyond the fifth day. This 
item/service falls within the inpatient services in a psychiatric hospital. 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 mental health stay provided from August 29, 2023, to 
September 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures are bothering you 
and you are requesting a new service. The Plan denied your request. The Plan says your benefit for the 
requested items or services 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 for a partial upper denture (D5225) and a partial lower denture (D5226) on June 21, 2022; 
therefore, your benefit for the requested items or services was exhausted on the date of service of June 21, 
2022. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a 
partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on June 28, 
2023. 
 
You asked the Plan to pay for the non-emergent services. You say that the transport method was recommended 
by the enrollee's surgeon. The Plan denied your request. The Plan says transportation to or from a doctor's 
office is not a Medicare covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided on 
June 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport on May 11, 2022. 
 
You asked the Plan to pay for an ambulance transport. You say that you did not have the proper insurance 
information during the date of service. The Plan denied your request. The Plan says the claim is untimely. 
 
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 claim for ambulance transport was not filed until August 23, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance transport on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture 
(D6111). 
 
You asked the Plan to pre-approve 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 pre-approve an 
implant /abutment supported removable denture (D6111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. The cause of pain is not clear.  
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on August 7, 2023. 
 
You asked the Plan to pay for the hospital services. You say that the services should be covered as you disagree 
with the denial. 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 hospital services provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that you need a bottom replacement because you 
lost your previous denture. 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 the Plan paid for a complete lower denture (D5120) on January 11, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of January 11, 2023. Therefore, we decided that 
the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #29, a pontic 
(D6245) for tooth #28, a retainer crown (D6740) for tooth #27 and #29, and an extraction (D7210) for tooth 
#28 to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to reprocess the 
pre-determination because you are an in-network provider and you do not know why the dental services are 
denied. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by the enrollee's supplemental benefits. Also, it was verified that the requesting provider is an OON 
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 are requesting dental services to be provided by an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the pontic, a retainer crown, and the extraction are not covered 
under this benefit when received from an out-of-network provider. The core buildup is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core buildup 
(D2950) for tooth #29, a pontic (D6245) for tooth #28, a retainer crown (D6740) for tooth #27 and #29, and an 
extraction (D7210) for tooth #28 to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings will help with your legs. The Plan denied your request. The Plan says the requested stockings is not 
covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.