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 October 11, 2021 billed with 
codes 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, 81355, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 
October 11, 2021 billed with codes 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, 
81355, and 81401.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp vitality test on tooth #31 (D0460) and cone beam 
imaging (D0364) provided June 2, 2022. 
 
You asked the Plan to pay for vitality test and imaging. You say that you thought these services were covered. 
The Plan denied your request. The Plan says a pulp vitality test (D0460) and cone beam imaging (D0364) are 
not covered by your 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 pay for a pulp 
vitality test on tooth #31 (D0460) and cone beam imaging (D0364) provided June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 benefit allowance 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 Plan's 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 03/16/2021. Therefore, 
we decided that the Plan does not have to pay for dental services provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported removable denture on 
tooth #17 (D6111). 
 
You asked the Plan to pre-approve a supported denture. You say that this service should be covered. The Plan 
denied your request. The Plan says an implant/abutment supported removable denture (D6111) is not covered 
by your dental 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 pre-approve an 
implant/abutment supported removable denture on tooth #17 (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
5, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dental appointment was in a different 
office, and your last appointment was over six months ago. 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 February 8, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D9630, D4381, D4342, D4921) on March 
25, 2022. 
 
You asked the Plan to pay for dental services (D9630, D4381, D4342, D4921). You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says Our records indicate the 
member did not contact the plan prior to the date of service to verify benefits and provider eligibility. This 
means they will not receive a reimbursement for their claim cost. 
 
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 dental 
services (D9630, D4381, D4342, D4921) on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2022. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 19, 2022.
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 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider 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 Plan's coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental cleaning (D1110) and periodontal maintenance 
(D4910) provided by OON provider on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentist told you that you needed these 
services, and they should be covered. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a dental cleaning (D1110) and periodontal maintenance (D4910) provided by OON provider on 
October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) 
vaccine rendered on March 21, 2022. 
 
You asked the Plan to pay for these services. You say that you were not told by the provider that you would 
have to pay for the services. The Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis 
(TDaP) vaccine rendered on March 21, 2022.   
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Botox injection provided on November 8, 2021, and cone 
beam image capture provided on November 22, 2021. 
 
You asked the Plan to pay for the Botox injection and cone beam image capture. You say that you have severe 
pain and lack quality of life. You say that you need a dentist with this training and all your dental visits are 
medically necessary. The Plan denied your request. The Plan says the Botox injection was not medically 
necessary, and the cone beam image capture is not a covered benefit. 
  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. The 
rules also say that Medicare generally does not cover dental services, so the Plans coverage rules apply in this 
case. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Botox injection. Our reviewer says that 
Botox for temporomandibular joint (TMJ) dysfunction is an off-label use of the drug. Our physician reviewer 
found that the FDA has not approved the use of Botox for TMJ dysfunction. In addition, the cone beam image 
capture is not a service covered under your dental benefit.  
 
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 Botox injection and cone beam image capture have not been met. Therefore, 
we decided that the Plan does not have to pay for the Botox injection provided on November 8, 2021, and cone 
beam image capture provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided on January 
28, 2022, and March 1, 2022. 
 
You asked the Plan to pay for the infrared therapy services (97026). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says infrared therapy is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Specifically, infrared therapy is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy services (97026) provided on 
January 28, 2022, and March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more towards an extraction of an erupted tooth (D7210), a bone 
replacement graft (D7953) and guided tissue regeneration (D4266) provided on October 28, 2021. 
 
You asked the Plan to pay more towards an extraction of an erupted tooth (D7210), a bone replacement graft 
(D7953) and guided tissue regeneration (D4266). You say that you are on a fixed income. You also say that 
this bill creates a hardship for you. The Plan denied your request. The Plan says that you exhausted the $1,000 
yearly allowance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The 2021 Evidence of Coverage was not submitted to be able to determine if 
there is a benefit maximum to be met. Therefore, we decided that the Plan has to pay more towards an 
extraction of an erupted tooth (D7210), a bone replacement graft (D7953) and guided tissue regeneration 
(D4266) provided on October 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on April 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plan's 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 03/12/2021. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of any limitations for this 
service. 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 Plan's 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 July 29, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on April 5, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you needed the testing for a cruise. The Plan denied 
your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on April 5, 2022 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 4, 
2021, to October 13, 2021. 
 
You asked the Plan to pay for SNF care. You say that you believe that this SNF stay should be covered due to 
medical necessity. The Plan denied your request. The Plan says the enrollee was medically stable and 
independent with therapies. Daily skilled care was not required. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the beneficiary is a female with congestive heart failure who was admitted to the SNF 
on October 4, 2021. From a nursing perspective, the beneficiary received oral medications. The beneficiary had 
stable vital signs. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. 
Upon evaluation, the beneficiary was at a standby to supervision/touch assist level for functional mobility 
including gait. The beneficiary required varying assist with daily living activities.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy was not required on a daily basis. This beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 4, 2021, to October 13, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from August 1, 2021, 
to August 12, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file shows that the provider stated they sent medical records to be reviewed. 
The Plan made their determination based on the clinical documentation not supporting a mechanically altered 
diet being received during the 7 day look back period. However, the Plan has not provided these medical 
records for review. The Plan only provided the Minimum Data Set (MDS) Resident Assessment and Care 
Screening form. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care 
provided from August 1, 2021, to August 12, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 10, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided by a participating 
provider on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sunglasses purchased on April 8, 2022. 
 
You asked the Plan to pay for these services. You say that you would like reimbursement for the normal 
prescription eyewear. The Plan denied your request. The Plan says the services exceed the benefit limit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 for routine contact lenses or eyewear every year. 
 
We looked at the file and the Plan's rules. The file shows that you received sunglasses and were advised by 
phone call on April 5, 2022 sunglasses were not covered by the routine vision benefit. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the sunglasses purchased on April 8, 2022.