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

 
We decided that the Plan does not have to pay for the genetic testing provided on March 4, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 4, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 
81335, and 81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your upper dentures do not fit well. 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 May 24, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the comprehensive oral examination 
(D0150) and the intraoral-complete series of radiographic images (D0210) provided on March 9, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the comprehensive oral examination (D0150) and the intraoral-complete series of 
radiographic images (D0210) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 21, 
2022. 
 
You asked the Plan to pay for the dental services. 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 20, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and bone graft at 
time of implant placement (D6104). 
 
You asked the Plan to pre-approve the tissue regeneration and bone graft. The Plan denied your request. The 
Plan says these services are not covered under the enrollee's dental benefit 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 
guided tissue regeneration (D4266) and bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) X 2, 
complete denture - maxillary (D5110), and extraction, erupted tooth (D7210) X 9. 
 
You asked the Plan to pre-approve the dental services. You say that you lost your job and need assistance 
paying for the dental services. The Plan denied your request. The Plan says these services 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 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 
periodontal scaling and root planing (D4341) X 2, complete denture - maxillary (D5110), and extraction, 
erupted tooth (D7210) X 9.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 fractions of intensity modulated radiation therapy (IMRT) for 
the enrollee. 
 
You asked the Plan to pre-approve 10 fractions of IMRT. You say that the member has post-surgery nodular 
seeding and does not have leptomeningeal disease. The Plan denied your request. The Plan says that that there 
is no current research showing that your type of cancer responds better to the requested type of treatment than 
the type of treatment they can approve. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 10 fractions of IMRT. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Given the 
guidelines recognition of hippocampal sparing IMRT as a consideration in the setting of brain metastases and 
the fact that this patient does not have classic leptomeningeal disease hippocampal sparing, IMRT should be 
furnished in accordance with accepted standards of care. Our physician reviewer found that the enrollee's 
condition meets criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 fractions of IMRT have been met. Therefore, we decided that the Plan has to 
pre-approve 10 fractions of intensity modulated radiation therapy (IMRT) for the enrollee.  
 
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 pre-approve immediate denture - maxillary (D5130), mandibular 
partial denture (D5214), and interim complete denture - maxillary (D5810). 
 
You asked the Plan to pre-approve the dentures. You say that you have no back teeth and you need the dentures 
so you can eat. The Plan denied your request. The Plan says these services are not covered under your dental 
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 pre-approve 
immediate denture - maxillary (D5130), mandibular partial denture (D5214), and interim complete denture - 
maxillary (D5810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D5850, D7210, D7250). 
 
You asked the Plan to pre-approve dental services (D5850, D7210, D7250). You say that you say that you 
would like the plan to pay for all of the dental services being requested. The Plan denied your request. The Plan 
says the requested services are not covered under the enrollee's benefit 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 
dental services (D5850, D7210, D7250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removable maxillary denture 
(D6112). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. 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 October 7, 2019. 
Therefore, we decided that the Plan does not have to pre-approve an implant supported removable maxillary 
denture (D6112).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #6, 7, 8, and 9 (D3310), crowns 
on tooth #6, 7, 8, and 9 (D2740), core build up on tooth #6, 7, and 8 (D2950), and a prefabricated abutment on 
tooth #8 (D6056). 
 
You asked the Plan to pay for the full amount of the dental services. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says that there is only $468 remaining of the 
enrollee's annual dental allowance. 
 
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 when the annual dental allowance has been exhausted. Therefore, we 
decided that the Plan does not have to pay for endodontic therapy on tooth #6, 7, 8, and 9 (D3310), crowns on 
tooth #6, 7, 8, and 9 (D2740), core build up on tooth #6, 7, and 8 (D2950), and a prefabricated abutment on 
tooth #8 (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service rendered by a dentist or 
physician other than the requesting dentist or physician (D9310) on April 28, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service rendered by a dentist or physician other than the requesting dentist or physician (D9310) on 
April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electrocardiogram (ECG) (99215, 93000) 
provided on April 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and electrocardiogram. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 an office visit and electrocardiogram (ECG) 
(99215, 93000) provided on April 19, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep cleaning (D4341) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of calculus/tartar on the root surfaces, which is another sign of 
periodontitis - an infection of the supporting bone around the teeth. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the request has been made for two quadrants of scaling and root planing in the lower left (LL) and 
lower right (LR) quadrants. The provided records include periodontal charting and periapical and bitewing x-
rays. The teeth in the lower left and right quadrants of the mouth show less than 2mm of bone loss as viewed in 
the x-ray set provided. The periodontal charting indicates three or less teeth in a quadrant with abnormal pocket 
readings in the LR and LL quadrants. In this case the pocket readings are abnormal in up to three teeth in a 
quadrant in the LR and LL, but there is no notable bone loss seen in those areas on the provided x-rays. It is 
notable that pocket depth readings may be increased in areas of gingival inflammation and these are not caused by a periodontal disease condition requiring the requested services. Given that D4341 requires that four or 
more teeth in a quadrant be affected with loss of clinical attachment as seen by loss of supporting bone, the 
present request does not meet the criteria for the requested services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve deep cleaning (D4341) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration - resorbable barrier, per site (D4266). You say 
that you would like to request reconsideration of the denied authorization. The Plan denied your request. The 
Plan says the service is not a covered benefit under the member's benefit 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 
guided tissue regeneration - resorbable barrier, per site (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and cone beam computed 
tomography (CT) capture and interpretation with limited field of view  less than one whole jaw (D0364) 
provided March 28, 2022. 
 
You asked the Plan to pay for the pulp vitality tests and cone beam CT scan. You say that you were not 
informed prior to the services being rendered that they would not be covered. The Plan denied your request. 
The Plan says these services are 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 pulp vitality tests (D0460) and cone beam computed tomography (CT) capture and interpretation with limited field 
of view  less than one whole jaw (D0364) provided March 28, 2022.  
 
Your complaint about potentially receiving misinformation from representatives after the services were denied 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #31 (D2950), a pontic on tooth 
#30 (D6241), and retainer crowns on tooth #29 and 31 (D6750). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says core build 
up (D2950), a pontic (D6241), and retainer crowns (D6750) are not covered by your supplemental dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up on tooth #31 (D2950), a pontic on tooth #30 (D6241), and retainer crowns on tooth #29 and 31 
(D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited problem focused exam (D0140) provided May 3, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you feel your $1,000 should be accepted 
anytime. 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 12, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited problem focused exam (D0140) 
provided May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral, complete series of radiographic images (D0210) 
on May 2, 2022. 
 
You asked the Plan to pay for an intraoral, complete series of radiographic images (D0210). You say that you 
would like to request reconsideration for payment. The Plan denied your request. The Plan says the 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 
intraoral, complete series of radiographic images (D0210) on May 2, 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 tests 
(D0460) provided on March 15, 2022, and the surgical placement implant body (D6010) and prefabricated 
abutment and placement (D6056) provided March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford these services. The Plan 
denied your request. The Plan says the limited oral evaluation (D0140), pulp vitality test (D0460), surgical 
placement implant body (D6010), and prefabricated abutment and placement (D6056) are not covered under 
your supplemental 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 the 
limited oral evaluation (D0140) and pulp vitality tests (D0460) provided on March 15, 2022, and the surgical 
placement implant body (D6010) and prefabricated abutment and placement (D6056) provided March 28, 
2022.