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

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT 
code(s): 81404 and 81479) provided on August 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 documentation submitted on appeal indicates the cardiovascular genetic screening panel was initiated by 
the laboratory and not by the enrollee's treating physician. Therefore, we decided that the Plan does not have to 
pay for cardiac risk assessment genetic screening testing (CPT code(s): 81404 and 81479) provided on August 
13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on August 13, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81479) provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), take home drug 
(D9630), and unlisted periodontal procedure (D4999 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the dental provider advised you needed to 
go forward with the recommended noncovered procedures. You also say that the estimated cost of $718 is not 
affordable for you. 
The Plan denied your request. The Plan says the services denied correctly. 
 
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 take home drug and 
unlisted periodontal procedures are not among those covered under this benefit. Additionally, gingival irrigation 
is not covered when performed on the same day as other periodontal services. Therefore, we decided 
that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), take home drug (D9630), and 
unlisted periodontal procedure (D4999 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
device, and power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve controller, harness, electronic connection, and power seat elevation. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of 
authorization for these components is correct, because the enrollee's upper extremity strength and function are adequate to control the wheelchair's power options using their own switches. The Plan also says that a power 
seat elevation feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature. 
 
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 controller, harness, electronic 
connection, and power seat elevation. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 3 out of 5 
bilateral upper extremity strength with function and range of motion reported within functional limits, thus 
indicating that the enrollee has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of controller, harness, electronic connection, and power seat elevation have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, 
electronic connection device, and power seat elevation feature for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services. You say that this dental care is medically reasonable and 
necessary, and you do not wish to find a new provider. The Plan denied your request. The Plan says according 
to the Plan's contract, dental services provided by an OON provider are not covered. 
 
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 dental 
services only when they are rendered by a participating provider.  
 
We looked at the file and Medicare rules. In this case, the provider is not participating with the Plan. There are 
network providers available to provide the care you need. Based on this information, we decided that the Plan's 
rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve dental services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for tooth # 2. 
 
You asked the Plan to pre-approve the dental service. You say that your dentist advised you needed a tooth 
extracted for you to get the dentures that were made. The Plan denied your request. The Plan says the provided 
documentation does not indicate that the requested code is medically reasonable or 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 dental 
service 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 dental service. Our reviewer says 
that the requested dental service is not medically necessary. Our physician reviewer found the provided documentation indicates that the residual root is in soft tissue and would not require bone removal. Therefore, 
the reviewer found that the removal of residual tooth roots 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 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve removal of residual tooth roots (D7250) for tooth # 2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care/home management training (CPT code 97535) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 97535 is self-care/home management training (eg, 
activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and 
instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes.
 
We find that CPT code 97535 is not supported in the medical record. Specifically, CPT code 97535-GP 
remains not supported. The medical records submitted do not include documentation to support that self-care/home management training, direct one-on-one contact, each 15 minutes was performed. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for self-care/home management training (CPT code 97535) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidural injection provided on December 13, 2021.

You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says this provider has not submitted the required clinical records to support the medical necessity of the service for the date of service requested on appeal. The records provided to the health Plan are not dated and not signed. There is insufficient documentation of response to prior injection(s) and any recent physical exam and pain scale. 

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of an epidural injection provided on December 13, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural injection provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial denture adjustment (D5225), limited oral 
evaluation (D0140), periapical x-ray (D0220), and extraction (D7140) provided from August 31, 2020, to 
September 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you confirmed with a plan representative that 
the provider in this case is in network. The Plan denied your request. The Plan says the provider in this case has 
opted out of Medicare. The Plan also says that payment cannot be made for services rendered by a provider that 
hast 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services rendered by a provider 
that has opted out of Medicare are not among those covered under this benefit. Additionally, there is no record 
that the plan advised the provider in this case was in network. Therefore, we decided that the Plan does not 
have to pay for the partial denture adjustment (D5225), limited oral evaluation (D0140), periapical x-ray 
(D0220), and extraction (D7140) provided from August 31, 2020, to September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291, 99292) provided on October 
7, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says these services are not supported in the provided 
records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the critical care services (99291, 
99292) provided on October 7, 2021. have been met. Specifically, no medical records for the date in question 
were provided for review. Therefore, we decided that the Plan does not have to pay for the critical care services 
(99291, 99292) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on November 18, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that these services were provided to save 
your tooth and prevent a root canal. The Plan denied your request. The Plan says these procedures are not 
covered under your dental plan. 
 
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 the crown 
(D2740) and core buildup, including any pins when required (D2950) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2), endosteal 
implants (D6010 x 2), bone graft at time of implant placement (D6104 x 2), custom fabricated abutment 
(D6057 x 2), and abutment supported crown (D6058 x 2). 
 
You asked the Plan to pre-approve guided tissue regeneration and implant related services. You say that 
implants were covered when you signed up for your plan. You also say that you thought they still were. The 
Plan denied your request. The Plan says the requested services are not listed as covered. 
 
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 guided tissue regeneration and 
implant related services are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve guided tissue regeneration (D4266 x 2), endosteal implants (D6010 x 2), bone 
graft at time of implant placement (D6104 x 2), custom fabricated abutment (D6057 x 2), and abutment 
supported crown (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two retainer crowns (D6750 x2) provided on January 17, 2022. 
 
You asked the Plan to pay for the retainer crowns. You say that you would like these services to be paid in full. 
The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
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, crowns are limited to 2 procedure 
codes per calendar year. The record shows that you received two pontics (D6242 x2) on January 17, 2022 
which were processed by the Plan using your crowns benefit, and your crowns benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the two retainer crowns (D6750 x2) provided on 
January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior 
(D2394) for tooth 9 provided January 24, 2022. 
 
You asked the Plan to pay for the filling. You say that your filling fell out and needed to be replaced. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 filling 
once per tooth every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a filling for tooth 9 
was previously covered on October 28, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the filling has been exceeded. Therefore, we decided that the Plan does not have to pay for 
the resin-based composite - four or more surfaces, posterior (D2394) for tooth 9 provided January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four alveoloplasties in conjunction with extractions 
(D7310 x4) provided on February 2, 2022. 
 
You asked the Plan to pay for the alveoloplasties. You say that due to being on a fixed income, you told the 
dentist you did not want any services provided that would not be covered by your insurance. You also say that 
you were reassured that these services were covered. The Plan denied your request. The Plan says this service 
is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to 
this date of service to verify 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 the four 
alveoloplasties in conjunction with extractions (D7310 x4) provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered from December 12, 2020 to 
December 28, 2020. 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 the services were not billed correctly 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered from December 12, 2020 to December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) January 26, 2022. 
 
You asked the Plan to pay for the tooth extractions. You say that the Plan should have paid for your 
extractions. 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 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 the 
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021.

You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says this provider has not submitted the required clinical records to support the medical necessity of the service for the date of service requested on appeal. The records provided to the health Plan are not dated and not signed. There is insufficient documentation of response to prior injection(s) and any recent physical exam and pain scale.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of an epidural injection provided on November 29, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve a lower partial denture. You say that you need a new lower denture. The 
Plan denied your request. The Plan says you will exceed the frequency limit for this service. 
 
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 a lower 
partial denture once every 7 12 years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial 
denture was previously covered on October 30, 2019.  Based on this information, we decided that the Plan's 
frequency limit for coverage of a lower partial denture will be exceeded with the requested service. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226).