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

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive oral 
evaluation (D0150) provided by an out-of-network provider on August 12, 2021. 
 
You asked the Plan to pay for intraoral imaging and a comprehensive oral evaluation. You say that you feel 
like the Plan should pay for this. The Plan denied your request. The Plan says services provided out-of-network 
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 Plan's coverage rules apply in this case. The Plan covers intraoral 
imaging and a comprehensive oral evaluation when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of intraoral imaging and a comprehensive oral evaluation have not been met. Therefore, we 
decided that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive 
oral evaluation (D0150) provided by an out-of-network provider on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiological supervision rendered on May 25, 2021. 
 
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 are not separately payable. 
 
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, we have confirmed that codes 
75726, 75774, and 75726 are column II codes to column I code 37244. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the radiological supervision rendered on May 
25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing (81404) provided on July 
15, 2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage for genetic testing were not 
met.  
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 cardiovascular genetic testing 
provided on July 15, 2021, have been met. Specifically, the documentation from the enrollees provider does 
not include documentation regarding how the genetic testing results will be useful for managing the enrollees 
condition. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic testing 
(81404) provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noninvasive ear or pulse oximetry for oxygen saturation; 
multiple determinations (eg, during exercise) (CPT code 94761) provided on July 14, 2021. 
 
You asked the Plan to pay for the 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 94761 has a status indicator of 'T' on the CMS National Physician Fee Schedule (NPFS) Relative 
Value (RVU) file. This means this service is always bundled into another payable physician service, 96365 
billed the same day by the same provider. Therefore, we decided that the Plan does not have to pay for 
noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise) (CPT 
code 94761) provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81235, 
and 81321) provided on March 15, 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81235, and 
81321) provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 80307) provided on 
December 14, 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 CPT code 80307 (1 unit) remains not supported. The Plan states the medical 
records provided do not include laboratory results for the CPT billed. The Plan states progress notes and the lab 
requisition were received; however, no laboratory results were received for the billed date of service. 
 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 laboratory services (CPT code 
80307) provided on December 14, 2021, have been met. The laboratory results were not provided to verify the 
service was completed or necessary. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code 80307) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing (81479) provided on November 
25, 2020. 
 
You asked the Plan to pay for the cardiac genetic testing. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the criteria for coverage were not 
met for this testing. 
 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 pay for the cardiac genetic testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is whether the requested genetic testing is medically appropriate and 
necessary. The test is described as a genetic based cardiovascular risk factor screening test in which multiple 
genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic 
or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic 
test. There is no evidence to support its role in this patient clinical management. In summary, the requested 
testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cardiac genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the cardiac genetic testing (81479) provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation  full mouth, after oral evaluation (D4346), gingival irrigation  per quadrant (D4921) 
and drugs or medicaments dispensed in the office for home use (D9630) provided December 7, 2021. 
 
You asked the Plan to pay for the scaling in presence of generalized moderate or severe gingival inflammation, 
gingival irrigation and drugs dispensed in the office for home use. You say that you don't feel you should have 
to pay for these services. 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 
scaling in presence of generalized moderate or severe gingival inflammation  full mouth, after oral evaluation 
(D4346), gingival irrigation  per quadrant (D4921) and drugs or medicaments dispensed in the office for home 
use (D9630) provided December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 
17, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you enrolled in this plan to have these 
particular dental benefits. The Plan denied your request. The Plan says this service is not covered because the 
provider has opted out of Medicare. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
periodontal maintenance when you see any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare.   
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2392) and surgical 
extraction (D7210) provided on December 13, 2021. 
 
You asked the Plan to pay more for the resin-based composite and surgical extraction. You say that you paid 
$384.00 for these services instead of $167.00 that you were supposed to have paid. The Plan denied your 
request. The Plan says these services were processed according to your dental plan's negotiated rate. The Plan 
also says that the provider was informed that they should reimburse you for payment. 
 
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, you are responsible for a 50% 
coinsurance for each of these services when they are provided in-network. Therefore, we decided that the Plan 
does not have to pay more for the resin-based composite (D2392) and surgical extraction (D7210) provided on 
December 13, 2021.  
 
Please Note: The record shows that the Plan has been in contact with the providers office, and as of April 13, 2022 they 
advised that you have not been reimbursed because the corporate office has not confirmed the Plans payment has 
cleared. The Plan says that the situation has been explained to you, and the providers office has been advised that they 
are responsible for reimbursing you the overpayment for these services. Please contact the providers office if you have 
any questions.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the abutment supported porcelain fused to metal crowns (high noble 
metal) (D6059) for teeth 13 and 19 provided January 7, 2021, with 50% coinsurance, up to the $2,000 annual 
maximum plan allowance according to the Plan contract. 
 
You asked the Plan to pay for the abutment supported crowns. You say that there is no exception in the contract 
stating that crowns on implants are not covered. You feel the crowns should be covered with 50% coinsurance. 
The Plan denied your request. The Plan says that implants and all related services are not covered under your 
benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 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 crowns with 50% coinsurance up to the $2,000 annual maximum plan allowance. 
 
We looked at the file and Medicare rules. The Plan contract does not clearly say that crowns on implants are 
not covered. Therefore, we decided that the Plan has to pay for the abutment supported porcelain fused to metal 
crowns (high noble metal) (D6059) for teeth 13 and 19 provided January 7, 2021, with 50% coinsurance, up to 
the $2,000 annual maximum plan allowance according to the Plan contract.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
with 81286, 81238, 81410 and 81411 provided March 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached appeal and 
reconsider the charges that were previously denied. The Plan denied your request. The Plan says genetic 
cardiovascular screening testing does not meet the definition of cardiovascular disease screening and does not 
meet Medicare coverage criteria. 
 
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, the laboratory services, 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 the cardiac risk assessment genetic screening testing coded with 81286, 81238, 81410 and 81411 provided 
March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110), and complete lower 
denture (D5120) provided on February 1, 2022. 
 
You asked the Plan to pay for the dentures. You say that you were advised the dentures were pre-approved. 
You say that you were advised that $900 would be covered. You also say that you should not have to pay this 
bill. The Plan denied your request. The Plan says dentures are not listed as a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper 
denture (D5110), and complete lower denture (D5120) provided on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy (19085-RT) provided on August 4, 2021. 
 
You asked the Plan to pay for code 19085-RT. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 19085 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
19085-RT have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy (19085-
RT) provided on August 4, 2021.
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): 81238, 81407, and 81408) provided on May 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 test was to check for family history of heart disease and the enrollee did not 
have any medical issues that prompted the need for this screening testing. 
 
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, the laboratory services, 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 cardiac risk assessment genetic screening testing (CPT code(s): 81238, 81407, and 81408) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on November 29, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the benefit limit for D0140 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 Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation per year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was provided on March 
25, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation 
have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided by a participating provider on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 20, 2022. 
 
You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says you are covered for comprehensive oral exams 
once every 36 months. Your last evaluation was April 15, 2021, which is less than 36 months ago. 
 
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. 
 
We looked at the file and the Plan's contract. The contract clearly says comprehensive oral evaluations are 
covered once every 36 months. The file shows your last evaluation was April 15, 2021, which is less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided September 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you were told this 
dentist was in-network. The Plan denied your request. The Plan says this claim was processed correctly 
according to your OON benefits. The Plan also says that they reviewed phone records and found that you were 
informed that the dentists in this office were in-network, however the services were provided by a visiting 
periodontist who is not part of the dental network. 
 
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 contract says that 
you may pay more if you use an OON provider. 
 We looked at the file and Medicare rules. The Plan provided documentation showing that the full allowed 
amount was covered for this service. You have been asked to pay the difference between the amount the Plan 
paid and the total cost billed by the OON provider. Therefore, we decided that the Plan does not have to pay for 
the comprehensive periodontal evaluation - new or established patient (D0180) provided September 3, 2021, by 
an out-of-network (OON) provider.  
 
Your complaint about potentially being provided confusing or incorrect information from a plan representative 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided January 19, 2022. 
 
You asked the Plan to pay for the hot or cold pack therapy. You say that you would like the claim to be paid. 
The Plan denied your request. The Plan says separate payment is not allowed for this service. 
 
The Plan must follow Medicare rules. The rules say that payment for hot or cold packs is bundled into the 
payment for other covered services and is not reimbursable. 
 
We looked at the file and Medicare rules. Payment for hot or cold packs is not separately reimbursable. 
Therefore, we decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided 
January 19, 2022.