Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a primary care (PCP) office visit and 
therapeutic injection provided on February 2, 2022. 
 
You asked the Plan to waive the deductible for the PCP visit and injection. You say that you feel that you were 
billed twice for the same visit. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $150 deductible which applies to certain items and services.  
 
The PCP visit and injection falls within the benefit category Physician/Practitioner Services, Including Doctor's 
Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the PCP visit and injection were received on February 2, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for a primary care (PCP) office visit and therapeutic injection 
provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the precision attachments, by report  
(D5862 x 4) and the implant/abutment supported removable denture for the lower arch (D6111) provided on 
February 14, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items provided are not covered 
under your contractual policy. 
 
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 dental items provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the precision attachments, by report (D5862 x 4) and the implant/abutment supported 
removable denture for the lower arch (D6111) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 14, 2021, billed with 
codes 81210 and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 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 
July 14, 2021, billed with codes 81210 and 81275.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 1, 2021 billed with codes 
81206, 81235, 81292, 81321, and 81301. 
 
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 
July 1, 2021 billed with codes 81206, 81235, 81292, 81321, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2393 x2) provided on 
March 25, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that you had no choice but to get this work 
done. You also say that the dentist strongly recommended it. 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, the Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on March 9, 2022, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the two resin-based composites (D2393 x2) provided on March 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) and complete 
mandibular dentures (D5120) provided on February 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want new dentures and for the insurance to 
cover them. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service September 28, 2018. 
Therefore, we decided that the Plan does not have to pay for complete maxillary dentures (D5110) and 
complete mandibular dentures (D5120) provided on February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) and the bone replacement graft for ridge preservation-per site (D7953) 
provided on February 23, 2022. 
 
You asked the Plan to pay for the dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the 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 the extraction 
of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and the bone replacement 
graft for ridge preservation-per site (D7953) provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prosthesis, multi-axial ankle, 
dynamic response foot, one piece system (L5979). 
 
You asked the Plan to pre-approve an ankle prosthetic. You say that the records provided shows supporting 
evidence for the replacement foot. The Plan denied your request. The Plan says the requested K3 components 
exceed your needs and cannot be covered. 
 
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 an ankle prosthetic. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the K3 level Multi-Axial Ankle, Dynamic Response 
Foot at issue in this case meets Medicare criteria for medically reasonable and necessary. Provided records 
from your treating medical provider do not document K3 level ambulation and records report that you use a 
cane at times for ambulation. This information is not supportive of a K3 level of ambulation to meet Medicare 
criteria for the requested prosthetic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle prosthetic have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an all-lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece 
system (L5979).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 17, 2021, billed with 
codes 81238, 81226, 81225, 81335, 81230, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 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 17, 2021, billed with codes 81238, 81226, 81225, 81335, 81230, 81241, 81291 and 81240.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 25, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are being overcharged for the 
service. 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 $110 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $110 copayment for an ultrasound. Ultrasounds fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 an ultrasound provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
upgrade, harness upgrade, and electronic connection between wheelchair controller and two or more power 
seating system motors. 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller upgrade, harness 
upgrade, and electronic connection between wheelchair controller and two or more power seating system 
motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. 
The rules also say that wheelchair accessories are only covered for certain indications. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is specifically not 
covered. The requested upgraded electronics are covered when there is a medical need to control the power 
options through the joystick. Review of the file shows that the enrollees upper limb strength and function are 
adequate for the enrollee to be able to control the power options using their own switches which are included in 
the allowance of the approved power options. This means there is no medical need to control the power options 
through the joystick. The power options can be controlled using their own switches. 
 
Based on this information, we decided that Medicare rules for coverage of a power seat elevation system, 
expandable controller upgrade, harness upgrade, and electronic connection between wheelchair controller and 
two or more power seating system motors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system, expandable controller upgrade, harness upgrade, and 
electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need a deep cleaning every four months. 
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 24, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the ultrasound provided on February 3, 2022, and 
dental services provided on February 22, 2022.  You asked the Plan to waive the cost for the ultrasound and dental services. You say that you called the plan to confirm services would be covered. 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 Plan's coverage rules apply in this case. Your contract with the Plan 
clearly says that you must pay 50% coinsurance for non-Medicare covered preventive and non-Medicare 
comprehensive dental services from an out-of-network provider.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract with the Plan clearly says you must pay a $235 
copayment for each Medicare-covered diagnostic radiology service other than CT scans performed at a hospital 
facility. 
 
You have been asked to pay a total of $247.74 for the ultrasound and dental services. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 3, 2022 Ultrasound $100.74 $235 $100.74 (allowed 
amount) 
February 22, 2022 Dental Services $294 50% $147 
TOTAL:    $247.74 
 
The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The dental services fall within the Dental 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 cost for the ultrasound provided on February 3, 2022, and dental services provided on February 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for complete maxillary dentures (D5110) 
provided on June 17, 2021. 
 
You asked the Plan to waive the cost share for the dentures. You say that you disagree with the denial of full 
payment for your dentures. The Plan denied your request. The Plan says your annual dental maximum has been 
exhausted. 
 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 have a $1,000 
annual allowance for all in-network covered preventive and comprehensive dental services. The contract also 
says that the enrollee must pay 100% of the charges beyond the $1,000 allowance. 
 
The record shows you have exhausted your annual allowance for dental services. You have been asked to pay 
the non-covered amount of $52 for the dentures received on June 17, 2021. Dentures fall within the Dental 
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 cost share for complete maxillary dentures 
(D5110) provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 10, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this code is not 
separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing at issue is considered validity testing, which 
is not separately payable. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on February 
23, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you feel this service should be covered 
for your cleaning. The Plan denied your request. The Plan says this service is not covered. 
 
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 full 
mouth debridement (D4355) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) provided on 
February 3, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you needed an emergency tooth pulled. You say 
there were no approved providers open within driving distance due to a bad snowstorm. You also say that the 
services should be covered as in network. 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. The Plan also 
says that the services were not emergent in nature. 
 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 oral evaluation, x-ray and extraction are not covered 
under this benefit when received from an out-of-network provider. Additionally, the bone replacement graft is 
not covered regardless of the provider's network status. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140), periapical x-ray (D0220), surgical extraction (D7210), and bone 
replacement graft for ridge preservation (D7953) provided on February 3, 2022, by the out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve the wheelchair. You say that it is hard for you to get around and for your 
caregiver to assist you. The Plan denied your request. The Plan says the enrollee does not meet the criteria as 
the enrollee is ambulatory and is currently using a walker. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the patient 
does not have mobility deficit that impairs their participation in MRADLs, the patients condition can be 
ameliorated by an appropriately fitted cane or walker, or the wheelchair is for use outside of the house.  
 
The file shows that your condition can be improved by a walker, cane. Specifically, the enrollee is ambulatory and is currently using a walker. Also a lightweight wheelchair for use outside of the home is not a covered 
benefit. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lightweight wheelchair (K0003).