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

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening coded 81404 
and 81442 provided on June 11, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit. 
 
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 cardiac risk assessment genetic screening at issue in this appeal 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 coded 81404 and 81442 provided on 
June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954), 
endodontic therapy, molar tooth (excluding final restoration) (D3330), and re-cement or re-bond fixed partial 
denture (D6930) provided March 30, 2022. 
 
You asked the Plan to pay for the prefabricated post and core, root canal and re-cement or re-bond fixed partial 
denture. You say that the Plan said they covered part of the cost but they did not. 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 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 the 
prefabricated post and core in addition to crown (D2954), endodontic therapy, molar tooth (excluding final restoration) 
(D3330), and re-cement or re-bond fixed partial denture (D6930) provided March 30, 2022.  
 
Your complaint about the Plan including confusing and/or misleading information in their denial 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 pay for a surgical extraction (dental code D7210) for tooth #31 
provided on February 8, 2022. 
 
You asked the Plan to pay for a surgical extraction. You say that you thought it was a basic procedure and did 
not know it was a surgical extraction. The Plan denied your request. The Plan says this service is not covered 
by the Plan's 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 surgical 
extraction (dental code D7210) for tooth #31 provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
x-ray (D0210), scaling and root planing (D4341 x 2), gingival irrigation (D4921 x 2), take home drugs 
(D9630), and extraction (D7140) provided from November 22, 2021, to December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised that your plan did not cover 
your cleaning which is incorrect. You say that your coverage covers this at 70%. You also say that your card 
shows that you have the plan that covers these services. The Plan denied your request. The Plan says the claims 
processed correctly. 
 
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 and comprehensive oral evaluation is 
covered once every 3 years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on June 30, 2021. Additionally, the x-ray, periodontal 
services, take home drugs, and extraction are not among those covered under this benefit. The record shows 
that you were no longer enrolled in the optional supplemental dental coverage as of October 1, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 
complete series x-ray (D0210), scaling and root planing (D4341 x 2), gingival irrigation (D4921 x 2), take 
home drugs (D9630), and extraction (D7140) provided from November 22, 2021, to December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite fillings (D2393 x 2) and gingivectomy 
(D4212 x 2) provided on February 28, 2022. 
 
You asked the Plan to pay for the fillings and gingivectomy. You say that these services were medically 
necessary. The Plan denied your request. The Plan says resin-based composite fillings (D2393) and 
gingivectomy (D4212) are not covered by the Plan's 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 resin-
based composite fillings (D2393 x 2) and gingivectomy (D4212 x 2) provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110), problem focused limited oral evaluation (D0140), first intraoral periapical x-ray 
(D0220), and resin-based composite (D2393) provided from November 8, 2021, to January 11, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, problem focused 
limited oral evaluation, first intraoral periapical x-ray, and resin-based composite. You say that you were under 
the impression that this organization was in-network with your plan. The Plan denied your request. The Plan 
says these services were rendered by a non-participating provider. The Plan also says that the dental services 
must be rendered by an in-network provider, or an approved prior authorization must be obtained prior to the 
OON dental services. 
 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), problem focused limited oral 
evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite (D2393) provided from 
November 8, 2021, to January 11, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on February 23, 2022. 
 
You asked the Plan to pay for the local anesthesia. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the 
date of service to verify 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zaltrap. 
 
You asked the Plan to pre-approve Zaltrap. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zaltrap. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided, 
guidelines of the National Comprehensive Cancer Network and the Medicare-approved major drug compendia 
there is no documentation that the Zaltrap meets Medicare criteria for safe and effective for the enrollee. 
Provided records do not document a medically-accepted indication for use of the Zaltrap. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zaltrap have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zaltrap.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the check-up examination (D0120), x-rays (D0274), and the 
adult dental cleaning (D1110) provided by an out-of-network dentist on April 4, 2022. 
 
You asked the Plan to pay for the check-up examination (D0120), x-rays (D0274), and the adult dental cleaning 
(D1110). You say that you were told by an insurance agent that this provider was in-network. You say you 
would not have been seen if you were told the dentist was out-of-network. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when rendered by an out-of-network dental provider. The record shows 
the rendering dental provider was out-of-network. Therefore, we decided that the Plan does not have to pay for 
the check-up examination (D0120), x-rays (D0274), and the adult dental cleaning (D1110) provided by an out-
of-network dentist on April 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43235) billed for date of 
service July 1, 2021. 
 You asked the Plan to pay for an esophagogastroduodenoscopy. You say that you have provided medical 
records to support the service billed. The Plan denied your request. The Plan says rules for payment have not 
been met because the services at issue are included in another billed code. 
 
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 code 43235 
is a column II code to column I code 43245 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for an esophagogastroduodenoscopy (43235) billed for date of service July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after July 14, 2022. 
 
You asked the Plan to pre-approve SNF care after July 14, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 pre-approve SNF care after July 14, 2022. Our 
reviewer says that you do not meet the Medicare criteria for continued SNF care. Our physician reviewer found 
you do not require skilled nursing or therapy services on a daily basis. You do 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing facility (SNF) care after July 14, 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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and panoramic 
x-ray (D0330) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you found this provider on the plan's website. 
You say that your dentist was not able to find the problem. You say that it was suggested you see an oral 
surgeon. You also say that the oral surgeon had to take new x-rays because the ones provided were not clear. 
The Plan denied your request. The Plan says 1 comprehensive oral evaluation and 1 panoramic x-ray are 
covered every 3 plan years. The Plan also says that the frequency limits have been exceeded. 
 
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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that 1 comprehensive oral evaluation and 1 
panoramic x-ray is covered every 3 plan years. The record shows that the Plan paid for these services that 
you received on January 28, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150), and panoramic x-ray (D0330) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be 
performed by an out of network dentist. 
 
You asked the Plan to pre-approve the dental service. You say that you previously saw this provider in 2016. 
You also say that you would like to continue seeing this provider due to your previous history. The Plan denied 
your request. The Plan says dental services performed 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental service is not 
among those covered under this benefit when performed out of network.  
 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to 
be performed by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) 
provided on March 7, 2022. 
 
You asked the Plan to pay for the scalings and planings. You say that you have a condition called periodontal 
pockets that requires you to undergo deep cleanings at certain scheduled times in order to avoid infections, 
bacteria, and potentially leading to periodontal pockets and potential surgery and/or gum disease and tooth loss. 
The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The 
Plan also says that you did not contact the Plan prior to the date of service to verify 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 two 
periodontal scalings and root planings (D4342 x2) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) and panoramic x-ray (D0330) provided on April 5, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images and panoramic x-ray. You say that before 
the x-rays were taken, you asked the office if your insurance covered the procedure and they indicated that yes 
it would be covered. The Plan denied your request. The Plan says the 2D oral/facial photographic images is not 
a covered expense under your dental plan. The Plan also says that your panoramic x-ray benefit has been 
satisfied and the frequency limitation has been exceeded. 
 
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 two dimensional (2D) oral/facial 
photographic image (D0350) is not among those covered under this benefit. The contract clearly states that full 
mouth or panoramic x-rays share a frequency limitation of 1 procedure code every 5 calendar years. The record 
shows that you received a complete series of intraoral x-rays (D0210) on April 5, 2022, which was covered by 
the Plan, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4) and 
panoramic x-ray (D0330) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says gingival irrigation is 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 requested gingival irrigation are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2752) provided on January 18, 2022. 
 
You asked the Plan to pay more for the crown. You say that you would like these services to be approved on a 
one-time basis. The Plan denied your request. The Plan says you have met your annual maximum 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, you are responsible for a $0 copay up 
to the $1,000 allowance for all covered dental services. The contract clearly states that you pay 100% of 
charges beyond the $1,000 allowance or if you exceed a service limit. The record shows that you met the 
annual maximum benefit while processing this claim for the January 18, 2022 date of service, and your annual 
maximum benefit has been exhausted. 
 
 
  
 
Therefore, we decided that the Plan does not have to pay more for the crown (D2752) provided on January 18, 
2022.