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

 
We decided that the Plan does not have to pay for diagnostic casts (D0470), an immediate mandibular denture 
(D5140), removable prosthodontic procedure (D5899), and an alveoplasty (D7310), provided by a participating 
provider on January 26, 2022, to February 16, 2022. 
 
You asked the Plan to pay for diagnostic casts, an immediate mandibular denture, removable prosthodontic 
procedure, and an alveoplasty. You say that these services were medically necessary. The Plan denied your 
request. The Plan says these services have been processed correctly. 
 
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 diagnostic 
casts (D0470), an immediate mandibular denture (D5140), removable prosthodontic procedure (D5899), and an 
alveoplasty (D7310), provided by a participating provider on January 26, 2022, to February 16, 2022.  
 
This appeal only addresses the denied dental services provided on January 26, 2022, to February 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on August 10, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation does not support the 
services billed. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the lab report clearly shows that 
22+ drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT 
codes 82415, 82542 and 84228 are not eligible for payment. It is the burden of the Health Plan to substantiate 
their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your 
favor. Also, the record indicates that this provider was directed by the Plan to not obtain records. With this 
direction, it is inappropriate for the Plan to deny these services based on the physician signature. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have been met. Therefore, we 
decided that the Plan has to pay for the drug testing provided on August 10, 2017.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine. 
 
You asked the Plan to pre-approve Buprenorphine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Buprenorphine.  
 
Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
December 3, 2021. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you feel 
this should be covered because the copayments are too high. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $325 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $325 copayment for a computerized tomography (CT) scan. A computerized 
tomography (CT) scan falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 computerized tomography (CT) scan on 
December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteogenesis stimulator. 
 
You asked the Plan to pre-approve Osteogenesis stimulator. You say that you feel this device is medically 
necessary. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Osteogenesis stimulators are only covered for certain 
indications. 
 
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 Osteogenesis stimulator. Our reviewer 
says that the documentation does not support that the requested device is medically reasonable or necessary. 
Our physician reviewer found the documentation shows that only L4-5 one level fusion surgery was done. Not 
enough time has passed to establish diagnosis of spine nonunion. Therefore, you do not meet criteria for the 
requested device. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Osteogenesis stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of injection is considered experimental and investigational. 
 
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 the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested genicular nerve block, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 29, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you believe the claim was coded 
incorrectly. The Plan denied your request. The Plan says periodontal maintenance (D4910) is not covered by 
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 Plan's 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 
periodontal maintenance (D4910) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), 
prophylaxis - adult (D1110), unspecified adjunctive procedure, by report (D9999) provided December 28, 2021. 
 
You asked the Plan to pay for the fluoride varnish, dental cleaning and unspecified adjunctive procedure. You 
say that you were only recently informed that this provider is out-of-network. The Plan denied your request. 
The Plan says these services are not covered because the provider has opted out of Medicare. 
 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. The Plan covers the fluoride 
varnish, dental cleaning and unspecified adjunctive procedure when you see any licensed dental provider who 
accepts Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the fluoride varnish, dental cleaning and unspecified adjunctive 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206), prophylaxis - adult (D1110), unspecified adjunctive procedure, by 
report (D9999) provided December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #29 (D2950) and a crown on tooth 
#29 (D2752) provided on December 9, 2021. 
 
You asked the Plan to pay for core build up and a crown. You say that you were unaware the dentist opted out 
of Medicare. The Plan denied your request. The Plan says this provider has opted out of Medicare and is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for core build 
up on tooth #29 (D2950) and a crown on tooth #29 (D2752) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided February 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lower partial denture. You say that this service was approved in July 2021. 
The Plan denied your request. The Plan says this service is not covered when provided OON. 
 
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 lower partial denture when the services are provided in-network. 
 
We looked at the file and Medicare rules. In this case the services were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the lower partial denture have not been met. 
Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
February 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like a scooter for when you are 
away from the home. The Plan denied your request. The Plan says the requested device is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve a dental surgery. You say that you cannot find in-network providers near 
you. The Plan denied your request. The Plan says services must be provided by a participating provider. 
 
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. The Plan covers covered 
dental services provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a dental surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve a dental surgery provided by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on November 12, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service billed. 
 
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 G0481 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the lab report clearly shows that 
8-14 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing provided on November 12, 2018.  
 
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 prophylaxis (D1110) provided on February 8, 2022, and 
bone replacement grafts (D7953 x 2), application of autologous blood concentrate (D7921), and extractions 
(D7140 x 2) provided on February 17, 2022. 
 
You asked the Plan to pay for prophylaxis, replacement grafts, application, and extractions. You say that you 
were never told that the dental plan does not pay for out-of-network dentists. The Plan denied your request. The 
Plan says these services are not covered when seen by 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 Plan's coverage rules apply in this case. 
 
The record shows you received 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 among those covered 
under this benefit when received by an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for prophylaxis (D1110) provided on February 8, 2022, and bone replacement grafts (D7953 x 2), 
application of autologous blood concentrate (D7921), and extractions (D7140 x 2) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation for moderate sedation (D9219) provided by an 
out-of-network provider on November 24, 2021. 
 
You asked the Plan to pay for an evaluation for moderate sedation. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the requested 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 an 
evaluation for moderate sedation (D9219) provided by an out-of-network provider on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 7, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that this was necessary. The Plan 
denied your request. The Plan says the benefit limit for D0150 has been met and 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. The Plan covers one 
comprehensive oral evaluation every 36 months.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on January 13, 2020. Based on this information, we decided that the Plan's rules for coverage of a 
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal on tooth #15 (D3330) and prefabricated post on 
tooth #15 (D2954) provided on February 28, 2022. 
 
You asked the Plan to pay for root canal and prefabricated post. You say that you called year to check that the 
provider was in-network. The Plan denied your request. The Plan says the services are not covered when seen 
by 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. 
 
The record shows you received 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 among those covered 
under this benefit when received by an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for a root canal on tooth #15 (D3330) and prefabricated post on tooth #15 (D2954) provided on 
February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and pulp vitality test 
(D0460) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a second opinion. You say that you 
did not want to do something drastic if it did not need to be done. You also say that you just want to get to the 
bottom of what is going on. The Plan denied your request. The Plan says limited oral evaluation is not listed as 
a covered service. The Plan says that pulp vitality test is not listed as a covered service either. 
 
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 limited oral evaluation and pulp 
vitality test are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140) and pulp vitality test (D0460) provided on March 2, 2022.