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

 
We decided that the Plan has to pay for the crown (D2740) and the core buildup (D2950) provided on July 7, 
2022. 
 
You asked the Plan to pay for the crown (D2740) and the core buildup (D2950). You say that you had pain on 
tooth #15. You say the dentist recommended a crown due to recurrent cavities under fill, and possible cracked 
tooth syndrome. The Plan denied your request. The Plan says that the services were not medically necessary. 
 
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 crown 
(D2740) and the core buildup (D2950) 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 pay for the crown (D2740) and the core buildup 
(D2950). Our reviewer says that the services are medically necessary. Our physician reviewer found you had 
pain and cold sensitivity in tooth #15. The x-rays showed a large alloy restoration and recurrent caries. Also, 
due to your symptoms, you were diagnosed with a possible cracked tooth. The treatment of removal of the 
current restoration and caries, a core buildup, and a crown restoration was medically reasonable and necessary. 
 
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 crown (D2740) and the core buildup (D2950) have been met. Therefore, we 
decided that the Plan has to pay for the crown (D2740) and the core buildup (D2950) provided on July 7, 2022.  
 
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: Lab
Decision: Favorable

We decided that the Plan has to pay for the Afirma test (CPT 81546-59) provided on June 8, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the records do not support that the criteria for coverage have been met.

The Plan follows Medicare rules. Medicare rules say that the test is covered for patients with one or more thyroid nodules with a history or characteristics suggesting malignancy and that have an indeterminate follicular pathology on fine needle aspiration.

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 the testing. Our reviewer says that the service is medically necessary. Our physician reviewer found the records support that the patient has one or more thyroid nodules with a history or characteristics suggesting malignancy, on the right with atypia and left with follicular neoplasm. The records support that the patient has an indeterminate follicular pathology on fine needle aspiration on the right.

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 testing have been met. Therefore, we decided that the Plan has to pay for the Afirma test (CPT 81546-59) provided on June 8, 2021. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for observation - no other services 
performed(D9430) provided on July 12, 2022. 
 
You asked the Plan to pay for the office visit for observation. You say that you would like the Plan to cover this 
service. The Plan denied your request. The Plan says this service is not covered under your 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 office 
visit for observation - no other services performed(D9430) provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel services provided on August 5, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the targeted genomic sequence analysis panel services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.



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 the targeted genomic sequence analysis panel services provided on August 5, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and chemotherapy services 
on June 9, 2022, and July 1, 2022. 
 
You asked the Plan to waive the copayment for an office visit and chemotherapy services. You say that you 
would like to appeal the cost share. 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 $35 
copayment and a 20% coinsurance for an office visit and chemotherapy services.  
 
 You have been asked to pay a $35 copayment and a 20% coinsurance for an office visit and chemotherapy 
services. This item/service falls within the Physician/Practitioner services, including doctors office visits and 
Medicare Part B prescription drugs benefit categories. 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 
an office visit and chemotherapy services on June 9, 2022, and July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on
May 4, 2022.

You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for an
approved indication. 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 F1CDx testing have
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx)
(0037U) testing provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation post-operative office visit (D0171) provided 
on August 2, 2022. 
 
You asked the Plan to pay for the re-evaluation post-operative office visit. You say that you had to go back to 
the dentist for treatment for the same problem. The Plan denied your request. The Plan says a re-evaluation 
post-operative office visit is not a covered procedure. 
 
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 re-
evaluation post-operative office visit (D0171) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D2950, and D2752). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 pre-approve the 
dental services (D2950, and D2752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray, crown and core buildup 
provided from May 2, 2022, to May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 intraoral periapical x-ray, crown and core buildup provided from May 2, 2022, to May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant tooth #'s 23, 26 (D6010), prefabricated abutment  includes modification and placement tooth #1 
(D6056), precision attachment, by report tooth #'s 1-32 (D5862), and overdenture  complete mandibular tooth 
#17-32 (D5865). 
 
You asked the Plan to pre-approve the dental services. You say that you have no bone structure to stick to, 
therefore you are requesting the implants. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 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 the 
surgical placement of implant body: endosteal implant tooth #'s 23, 26 (D6010), prefabricated abutment  
includes modification and placement tooth #1 (D6056), precision attachment, by report tooth #'s 1-32 (D5862), 
and overdenture  complete mandibular tooth #17-32 (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive oral evaluation 
(D0150), panoramic radiographic image (D0330), and the bitewings-four radiographic images (D0274) 
provided on May 19, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $15 
copayment for routine preventive dental services rendered by an in-network provider.  
 
You have been asked to pay $45 ($15 copayment x 3) for the routine preventive dental services rendered by an 
in-network provider. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the comprehensive oral 
evaluation (D0150), panoramic radiographic image (D0330), and the bitewings-four radiographic images 
(D0274) provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve twelve acupuncture services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
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 acupuncture services. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found treatment of acupuncture is 
generally recommended on a limited basis for chronic musculoskeletal conditions and should be incorporated 
as part of a more active exercise program, it is not recommended as a stand-alone therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acupuncture services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve acupuncture services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that the dentures you received in April were don 
incorrectly. You say that the dentures fall down and do not fit in your mouth. You say that you cannot eat 
without dentures. You also say that you cannot pay for this yourself. The Plan denied your request. The Plan 
says your benefits for the requested dentures have 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 benefits for the requested complete upper and partial lower dentures were exhausted on date of 
service April 20, 2022. Therefore, we decided that the Plan does not have to pre-approve a complete upper 
denture (D5110), and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) of chest with dye (71260), and CT of pelvis with dye (74177).

You asked the Plan to pre-approve the CT scans. You say that the requested services are medically necessary. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scans. Our reviewer says that the requested CT scans are medically necessary. Our physician reviewer found the provided documentation indicates baseline imaging studies followed by an objective 10-pound weight loss over 10 months (between December 15, 2021, and September 6, 2022). The reviewer found that the provided documentation indicates that the requested interval CT imaging is both reasonable and medically necessary at this time. 

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 CT scans have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) of chest with dye (71260), and CT of pelvis with dye (74177). 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown anchored to an implant abutment (D6058) for 
tooth #19 provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a custom crown completed so it 
could fit an implant. 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 the date of service of June 29, 2020. 
Therefore, we decided that the Plan does not have to pay for the crown anchored to an implant abutment 
(D6058) for tooth #19 provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 your benefit for the requested items or services was exhausted on date of service June 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 84443 
 
You asked the Plan to pay for code 84443. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this screening test is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 84443, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
services billed with code 84443
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision of a gum lesion (41823). 
 
You asked the Plan to pre-approve the excision of a gum lesion (41823). You say that you need help, and you 
are dying. You also say that you need help before you do anything that you cannot control, and you are not 
going to deal with people outside. The Plan denied your request. The Plan says this service is not covered under 
the Medicare line of business or 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 pre-approve the 
excision of a gum lesion (41823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all-white glass crown (D2740) on tooth #8. 
 
You asked the Plan to pre-approve the all-white glass crown (D2740) on tooth #8. You say that your tooth is 
sensitive and hurts. You say you need the crown approved. The Plan denied your request. The Plan says the 
service does not meet criteria. 
 
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 all-white 
glass crown (D2740) on tooth #8 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 all-white glass crown (D2740) on 
tooth #8. Our reviewer says that the service is not medically necessary. Our physician reviewer found the x-
rays provided were not of diagnostic quality. The documentation provided was inadequate to determine if the 
criteria of coverage have been met. 
 
 
 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 all-white glass crown (D2740) on tooth #8 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the all-white glass crown (D2740) on tooth #8.