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

 
We decided that the Plan does not have to pay for the gene panel testing provided on October 4, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies actionable gene 
alterations. The Plan denied your request. The Plan says the request does not meet Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis 
(D1110), the complete series of intraoral x-rays (D0210), and the topical application of fluoride varnish 
(D1206) provided by an out-of-network provider on April 22, 2022. 
 
You asked the Plan to pay for the intraoral x-rays (D0210) and the topical application of fluoride varnish 
(D1206). You say that you searched the Plan's website with your zip code and the treating provider was 
included in the search results. You say the services should be covered as in-network. The Plan denied your 
request. The Plan says the services 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 intraoral x-rays (D0210) and the 
topical application of fluoride varnish (D1206) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis 
(D1110), the complete series of intraoral x-rays (D0210), and the topical application of fluoride varnish 
(D1206) provided by an out-of-network provider on April 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
refused to go to the hospital in order to spend less money, and would like this service to be covered. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 11, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and fillings (D2332, 
D2335) provided on March 22, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you lost two fillings within two days. You say 
you called your regular dentist whom your plan approved in 2021. You say that you thought there was no 
problem with insurance. You also say that you needed service quickly. 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 oral evaluation and fillings 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 limited oral evaluation (D0140), and fillings (D2332, D2335) provided on March 22, 2022, by 
the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the maxillary immediate denture (D5130) provided on 
May 17, 2022. 
 
You asked the Plan to pay in full for the maxillary immediate denture. You say that a Plan representative 
advised that dentures were covered 100% under your plan. The Plan denied your request. The Plan says this 
claim processed correctly according to your benefits. The Plan also says that you contacted the Plan on June 4, 
2021, when you were under a different plan, and did have full coverage for dentures at that time. 
 
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 contract says that you are 
responsible for a 50% coinsurance for an immediate denture rendered by an in-network provider. Therefore, we 
decided that the Plan does not have to pay in full for the maxillary immediate denture (D5130) provided on 
May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
and comprehensive oral evaluation (D0150) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental exam was not adequate. 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 date of service April 20, 2021. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) and comprehensive oral evaluation (D0150) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and 
panoramic radiographic image (D0330) provided on February 21, 2022, the immediate denture (D5140) 
provided on March 2, 2022, and the extractions (D7140) provided on March 24, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were told you would not have to pay 
anything for these services. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) 
and panoramic radiographic image (D0330) provided on February 21, 2022, the immediate denture (D5140) 
provided on March 2, 2022, and the extractions (D7140) provided on March 24, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) and adjustment of the 
maxillary complete denture (D5410) provided on April 5, 2022. 
 You asked the Plan to pay for the preventive procedure and adjustment of the maxillary complete denture. You 
say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says 
these services will not be covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the preventive procedure (D1999) is 
not among those covered under this benefit. The contract says that you are allowed one denture adjustment 
every 12 months. The record shows that you received an adjustment of the maxillary complete denture (D5410) 
on March 1, 2022, and your denture adjustment benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the preventive procedure (D1999) and adjustment of the maxillary complete denture 
(D5410) provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on June 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on April 12, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral 
evaluation. You say that this is the first time you went to this doctor to determine the cause of pain in your 
upper right teeth, and believe it is the first time a claim for services was submitted for this. You also say that 
you would like a one-time exception made to the policy. The Plan denied your request. The Plan says the cone 
beam CT capture and interpretation is not covered under your plan. The Plan also says that the problem focused 
limited oral evaluation does not meet the frequency requirements of 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 cone beam CT capture and 
interpretation (D0364) is not among those covered under this benefit. The contract says that problem focused 
limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a 
problem focused limited oral evaluation (D0140) on February 22, 2022, and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the cone beam computed tomography (CT) capture and interpretation (D0364) and problem focused limited 
oral evaluation (D0140) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine provided on October 25, 2021. 
 
You asked the Plan to pay for the influenza vaccine. You say that the claim was for treatment of a non-terminal 
condition and was unrelated to hospice. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the influenza vaccine provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - lower (D5120) and complete denture 
- upper (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are having problems chewing food and 
as a result, you are experiencing digestive issues, along with weight loss. 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 date of service January 16, 2019. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - lower (D5120) and 
complete denture - upper (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on April 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that clinical indications will not be enforced during 
the pandemic. The Plan denied your request. The Plan says the documentation did not include a valid physician 
order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The medical records do not show the 
physicians intent for the device to be ordered or used by the enrollee. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the continuous glucose monitor provided on April 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and resin-
based composite (D2332) provided on August 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says your benefits for the requested services 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 services were exhausted on dates of service May 11, 2020, and April 8, 
2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 
first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), 
and resin-based composite (D2332) provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen (E0431, E1390). 
 
You asked the Plan to pre-approve the home oxygen. You say that the oxygen is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 home oxygen. Our reviewer says 
that the requested oxygen is not medically necessary. Our physician reviewer found recent records document 
oxygen saturation levels of 91% to 96% on room air. 
 
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 home oxygen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home oxygen (E0431, E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on March 16, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was specifically requested by the 
enrollee's physician. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomics panel testing provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards (K0108) for a wheelchair. 
 
You asked the Plan to pre-approve side guards. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have 
not been met because the requested item is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve side guards (K0108) for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adult dental cleaning (D1110) provided May 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that your benefits read you get two cleanings per 
year. You also say that this was your first cleaning for the year. The Plan denied your request. The Plan says 
your benefit for the prophylaxis 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 date of service November 11, 2021. 
Additionally, the record shows you would not be eligible for a covered adult dental cleaning until June 30, 
2022. Therefore, we decided that the Plan does not have to pay for the adult dental cleaning (D1110) provided 
May 24, 2022.