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

 
We decided that the Plan does not have to waive the copayment for the unclassified drugs (J3490), intravitreal 
injection of a pharmacologic agent (67028), scanning computerized ophthalmic diagnostic imaging (92134), 
and compounded drug (J7999) provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you would like to 
appeal this service. The Plan denied your request. The Plan says the copayment amount you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment for Outpatient hospital surgery services.  
 
 You have been asked to pay a $195 copayment for the outpatient surgery services. These outpatient surgery 
services fall within the Outpatient hospital surgery services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for the unclassified drugs (J3490), intravitreal injection of a pharmacologic agent 
(67028), scanning computerized ophthalmic diagnostic imaging (92134), and compounded drug (J7999) 
provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 6, 2021, billed with 
code 81235. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says they have agreed to 
overturn and pay for the other services; however, 81235 remains denied as this was part of a genetic testing 
panel which was billed with individual gene codes rather than a single panel code as required. 
 
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 
August 6, 2021, billed with code 81235.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network chiropractic care provided 
on June 4, 2021. 
 
You asked the Plan to waive the copayment for chiropractic care. You say that you thought the provider was in 
network and if you would have known how much the copayment would have been you wouldn't have gone. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $15 
copayment for each Medicare covered chiropractic visit.  
 
You have been asked to pay $15 copayment which is less than the standard $55 copayment for out of network 
chiropractic care. Chiropractic care falls within the Chiropractic Services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for out of network chiropractic care provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medical studies haven't proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration (D2751) provided by a participating 
provider. 
 
You asked the Plan to pre-approve a crown restoration. You say that D2751 is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for D2751 has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown 
restoration when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown restoration. Our physician 
reviewer found the x-rays provided do not show that the criteria for coverage for a crown restoration for tooth 
#8 has not been met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown restoration have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown restoration (D2751) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from October 1, 2021, to 
December 17, 2021. 
 
You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says a licensed 
acupuncturist is a non-covered provider type and the provider is not supervised by any physician, physician 
assistant, nurse practitioner or a clinical nurse specialist. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services provided 
from October 1, 2021, to December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, of a molar tooth (excluding final 
restoration) (D3330).  
 
You asked the Plan to pre-approve this dental service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services received 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 Plans coverage rules apply in this case. 
 
You are requesting a dental service from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested service is 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 endodontic therapy, 
of a molar tooth (excluding final restoration) (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a periodic oral evaluation (D0120), 
and bitewings (D0274), provided by an out-of-network provider on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 Plan's 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 prophylaxis (D1110), a periodic oral evaluation (D0120), and bitewings (D0274), provided by an 
out-of-network provider on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental cleaning (D1110) and an unspecified preventive 
procedure (D1999) performed by an OON provider on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the dentist was a participating 
provider. The Plan denied your request. The Plan says the dental services were received from an OON 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 an unspecified preventive procedure (D1999) performed by an out-of-
network (OON) provider on March 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a medial branch block. 
 
You asked the Plan to pre-approve a medial branch block. You say that you need the injection and your 
primary care provider said you need the injection as therapy will not do any good. The Plan denied your 
request. The Plan says that a medial branch block does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 a medial branch block. Our reviewer 
says that a medial branch block is medically necessary. Our physician reviewer found that you have previously 
had a trial of physical therapy and a home exercise program. The request is medically reasonable and 
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 a medial branch block have been met. Therefore, we decided that the Plan has 
to pre-approve a medial branch block.  
 
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 a comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were assured that dental was included as 
part of your policy. The Plan denied your request. The Plan says your benefit for the  comprehensive oral 
evaluation has already been exhausted. The plan also says the intraoral radiographic images are not among the 
services 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 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 comprehensive oral evaluation (D0150) was exhausted on date of service February 
17, 2021. The record also shows the intraoral - complete series of radiographic images (D0210) are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) and intraoral - complete series of radiographic images (D0210) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
17, 2021. 
 You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided by an out-of-
network provider on April 21, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you have a broken crown. You say that 
you need this dental service. The Plan denied your request. The Plan says the rendered dental work 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 a cone 
beam CT capture (D0367) provided by an out-of-network provider on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the records there is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), the oral hygiene 
instructions (D1330), and the caries risk assessment and documentation (D0602) provided on March 28, 2022. 
 
You asked the Plan to pay 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 oral hygiene instructions and the caries 
risk assessment and documentation are not covered under your contractual policy. Additionally, you do not 
meet criteria for coverage of the comprehensive oral exam provided.  
 
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 oral hygiene instructions and the 
caries risk assessment provided are not among those covered under this benefit.  Additionally, the Plan 
contract says that a comprehensive oral exam is covered once every thirty six months. 
You previously received this service on November 8, 2019. Therefore, you do not meet criteria for coverage of 
this service provided. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
exam (D0150), the oral hygiene instructions (D1330), and the caries risk assessment and documentation 
(D0602) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #14, requiring sectioning of tooth 
(D7210) performed on March 23, 2022. 
 
You asked the Plan to pay for the tooth extraction. You say that you went for the cheapest and least painful 
option to fix your tooth. You say the extraction was needed to treat a tooth infection. The Plan denied your 
request. The Plan says the dental code D7210 is not included in the list of covered dental services; therefore, 
the decision to deny payment is correct. The Plan also says that you were not enrolled in the supplemental 
dental benefits at the time of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
extraction of tooth #14, requiring sectioning of tooth (D7210) performed on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Periodontal scaling and root planing (D4342, D4341) 
provided from April 14, 2022, to April 27, 2022. 
 
You asked the Plan to pay for the Periodontal scaling and root planing. You say that the services should be 
covered as you disagree with the denial and the provider performed services that you did not authorize. The 
Plan denied your request. The Plan says the services denied correctly as they do not fall within 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 pay for 
Periodontal scaling and root planing (D4342, D4341) provided from April 14, 2022, to April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns on tooth #3 and 5 (D6740) and a pontic on 
tooth #4 (D6245) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that retainer crowns (D6740) and pontics (D6245) 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 retainer 
crowns on tooth #3 and 5 (D6740) and a pontic on tooth #4 (D6245) provided on May 12, 2022.