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

 
We decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view 
(D0380) provided on May 12, 2021. 
 
You asked the Plan to pay for the cone beam CT. You say that the provider advised they were in network. You 
also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says cone beam CT 
image capture with limited field of view 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT image capture with 
limited field of view is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the cone beam CT image capture with limited field of view (D0380) provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a cystourethroscopy (52000) 
provided on October 8, 2021. 
 
You asked the Plan to pay for surgical assistant services. You say that this was requested by the primary 
surgeon. The Plan denied your request. The Plan says this cannot be paid as billed. 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 52000. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services on a cystourethroscopy (52000) provided on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the LTACH services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is improving but has not completed his hospital course of therapy and requires ongoing acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation 
(D0150), complete series x-ray (D0210), and adjunctive prediagnostic testing (D0431) provided on October 25, 
2021 by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the provider tried to sell 
you on treatments you feel you did not need for over an hour. You also say that these charges should be 
covered. The Plan denied your request. The Plan says the claim processed correctly. 
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 oral evaluation and x-ray are 
listed as covered, there is a 50% coinsurance that applies to the allowed amount for each service. Out of 
network providers may bill you for any amount greater than what the Plan pays the provider. Additionally, the 
adjunctive prediagnostic test is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay an additional amount for the comprehensive oral evaluation (D0150), complete series x-
ray (D0210), and adjunctive prediagnostic testing (D0431) provided on October 25, 2021 by the out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
September 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have several complaints. You say that you 
do not need to change providers in order to have coverage. You also say that your options are limited as there are only 6 dentists in your area, leaving you with few options. The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan says that payment cannot be made to providers that 
have 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services provided by a dentist 
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81227, 81230, 81240, 
81241, 81249, 81291, 81408, 81335, and 81355) provided on July 16, 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. As Comprehensive 
Genomic Profile testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily 
described by any existing CPT code. To report a comprehensive genomic profile provider should use 1-unit 
only of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved 
DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. 
Coverage of a Comprehensive Genomic Profile is limited to one test per specimen and precludes the use of any 
other molecular testing on the specimen. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 81227, 81230, 81240, 81241, 81249, 81291, 81408, 81335, and 81355) 
provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instruction (D1330), 2D photographic 
images (D0350 x 4), and panoramic x-ray (D0330) provided on October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that most of the imaging was not necessary since 
you already had a complete series of images done. You say that you only went to get your teeth cleaned. You 
say that you never got the fluoride treatment. You also say that you will not be paying anything more than what 
the Plan has already paid. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 panoramic x-ray is listed as 
covered, the frequency limit has been exceeded. One panoramic x-ray or diagnostic x-ray is covered every 3 
years. The record shows that the Plan paid for the diagnostic x-ray that you received on the date of service in 
this case, exhausting the frequency limit. Additionally, oral hygiene instruction and 2D photographic images 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the oral hygiene instruction (D1330), 2D photographic images (D0350 x 4), and panoramic x-ray (D0330) 
provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and unspecified 
preventive service (D1999) provided on November 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied 
your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 
the frequency limit has been exceeded. The Plan also says that unspecified preventive service is not 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on February 8, 2021. Additionally, the unspecified preventive 
service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and unspecified preventive service (D1999) provided on 
November 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) provided on 
September 10, 2021. 
 
You asked the Plan to pay for code 99283. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283 
is a column II code to column I code 99285. 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 emergency department visit (99283) provided on  
September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periapical x-ray. We decided that the Plan does not have to pay for 
the protective restoration.  
 
You asked the Plan to pay for the dental services. You say that you are enrolled in the optional supplemental 
dental coverage. You say that you cannot imagine that services performed in conjunction with a dental 
emergency due to cracking your tooth on a walnut shell would not be covered. You also say that your Evidence 
of Coverage does not clearly communicate that only specific dental codes are covered. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
We decided that the Plan has to pay for the periapical x-ray.  
 
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. Specifically, the file does not indicate that the enrollee has received other x-rays 
within the last 2 years that were covered. As such, we cannot determine if the frequency limit has been reached. 
Therefore, we decided that the Plan has to pay for the periapical x-ray.  
 
We also decided that the Plan does not have to pay for the protective restoration. 
 
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 protective restoration is not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the protective 
restoration. 
 
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 panoramic radio image (D0330), and an extraction (D7140) 
provided by a participating provider on December 1, 2021. 
 
You asked the Plan to pay for a panoramic radio image and an extraction. You say that you were told that you 
would not owe anything. The Plan denied your request. The Plan says services provided by a non-participating 
provider 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 a limited 
number of dental services 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 a panoramic radio image and an extraction have not been met. Therefore, we decided that the Plan 
does not have to pay for a panoramic radio image (D0330), and an extraction (D7140) provided by an out-of-
network provider on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants 
(D6010), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous 
moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) provided October 21, 
2021. 
 
You asked the Plan to pay for the endosteal implants and intravenous moderation sedation. You say that when 
you signed up for the plan you were under the impression that the necessary implants would be covered. The 
Plan denied your request. The Plan says the installation of an implant to replace a tooth missing prior to the 
effective date of coverage is not a covered benefit under your dental plan until the member has been active for 
24 consecutive months. 
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 does not cover 
implants for teeth that have been extracted prior to your effective date with the Plan unless you have been 
enrolled with the Plan continuously for more than 24 months.  
 
We looked at the file and Medicare rules. In this case you had not been covered by the Plan for 24 consecutive 
months prior to receiving the implants. Since no covered services were provided, the intravenous moderate 
sedation is also not covered. Based on this information, we decided that the Plan's rules for coverage of the 
endosteal implants and intravenous moderation sedation have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical placement of implant body: endosteal implants (D6010), intravenous 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) 
sedation/analgesia - each subsequent 15-minute increment (D9243) provided October 21, 2021.  
 
Your complaint about potentially receiving misinformation about plan benefits 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 dental services provided by a participating provider on 
November 23, 2021. 
 
You asked the Plan to pay for dental services. You say that you do not understand why you had to pay out-of-
pocket for this. The Plan denied your request. The Plan says there is a $1,000 allowance for non-Medicare 
covered dental services. 
 
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 a $1,000 
allowance for non-Medicare covered dental services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have already been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a participating provider on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified prosthodontic services (D5899 x 2) provided 
on November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like these services to be paid in full. 
The Plan denied your request. The Plan says the claim 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, the unspecified prosthodontic services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the unspecified prosthodontic services (D5899 x 2) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bitewing x-rays (D0274) provided on November 3, 2021. 
 
You asked the Plan to pay for bitewing x-rays. You say that you were not aware that this service would not be 
covered, and you cannot afford this expense. The Plan denied your request. The Plan says that you have already 
used this benefit this year. Code D0274 is covered for one procedure per plan year; however, this code is not 
covered in the same year as a full mouth set of x-rays (D0210). You had a periodic oral exam (D0120) on the 
same date, which was covered by the Plan and has been paid, and therefore this service is denied. 
 
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 set of 
bitewing x-rays for evaluation of the teeth and bone (D0270, D0272, D0273, D0274 or D0277) per plan year. 
Not covered in the same year as a full mouth set of x-rays (D0210). 
 
We looked at the file and the Plan's rules. The Plan states that you had a periodic oral exam (D0120) on the 
same date, and this service was covered by the Plan. The Plan argues that this means you have used your 
benefit for bitewing x-rays in 2021, and this service cannot be covered. However, your contract with the Plan 
states that this service may be covered once per year but will not be covered in the same year as a full mouth 
set of x-rays (D0210). This is not the same service as a periodic oral exam. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supplied any documentation that you have had a 
previous set of bitewing x-rays covered in 2021 or that you have had a complete series of x-rays provided 
which would exclude these bitewing x-rays from coverage. From the documentation provided, it appears that 
the Plan's denial is based on an erroneous reading of a billed procedure code. Based on this information, we 
decided that the Plan's rules for coverage of bitewing x-rays have been met. Therefore, we decided that the Plan 
has to pay for the bitewing x-rays (D0274) provided on November 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on September 17, 2020. 
You asked the Plan to pay for the respiratory pathogen panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the POS code used is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory pathogen panel have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the respiratory pathogen panel provided on September 17, 2020.