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

 
We decided that the Plan does not have to pay more for a complete series of radiographic images (D0210), a 
panoramic radiographic image (D0330), a comprehensive oral evaluation (D0150), and periodontal scaling and 
root planing (D4341 x4) provided on May 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought the provider was in-network. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. Additionally, your benefit 
for the panoramic radiographic image 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.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, the record shows your benefit for the panoramic radiographic image was exhausted on date of 
service May 13, 2022. Therefore, we decided that the Plan does not have to pay more for a complete series of 
radiographic images (D0210), a panoramic radiographic image (D0330), a comprehensive oral evaluation 
(D0150), and periodontal scaling and root planing (D4341 x4) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), or a core buildup (D2950). We decided 
that the Plan does not have to pay an additional amount for the fillings (D2391, D2330), and endodontic 
therapy (D3320) provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says they have paid their share of the cost of the covered dental services. 
You are responsible for the 50% coinsurance as stated in the Evidence of Coverage. Additionally, the crown 
and core buildup 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.  
 
   
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. The Plan has paid the correct amount for the covered 
services. Additionally, the crown and core buildup are not covered benefits. Therefore, we decided that the 
Plan does not have to pay for a crown (D2740), and a core buildup (D2950), or pay an additional amount for 
fillings (D2391, D2330), and endodontic therapy (D3320) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2332), complete series x-ray (D0210), and 
periodontal scaling and root planing (D4341) provided from April 15, 2022, to May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that on each date of service you received a cleaning. 
You say that you received a claim for payment for $625. You also say that you need some assistance for these 
visits. 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 and filling is listed as covered, there is 
a 50% coinsurance that applies to comprehensive dental services. This is a contractual obligation you agreed to 
when you enrolled in the Plans dental coverage. Additionally, the complete series x-ray and scaling and root 
planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2332), complete series x-ray (D0210), and periodontal scaling and root planing (D4341) 
provided from April 15, 2022, to May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown for tooth #21 (D2740) 
 
You asked the Plan to pre-approve the dental service. You say that the enrollees tooth is fractured, and a full 
coverage restoration is necessary to achieve a positive outcome. The Plan denied your request. The Plan says 
that the documentation does not indicate a reasonable argument for medical necessity. Specifically, the Plan 
says there is no evidence to indicate pathological destruction of tooth #21 by caries or by trauma involving 
three or more surfaces. The Plan also says that discoloration, deformity, and/or erosion do not fulfill the criteria 
for approval of a crown. 
 
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 the dental 
service 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 the dental service. Our reviewer says 
that the crown restoration is medically necessary. Our physician reviewer found the documentation provided 
meets the criteria for coverage of a crown restoration for tooth #21. Our reviewer carefully looked at the 
documentation and determined that tooth #21 shows a coronal fracture involving four surfaces. Therefore, a 
crown restoration is medically reasonable and necessary to restore tooth #21 to sufficient function for chewing. 
 
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 the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a porcelain/ceramic crown for tooth #21 (D2740)  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for mental health services provided from 
March 3, 2022, to May 19, 2022. 
 
You asked the Plan to waive the copayments for mental health services. You say that you were told you were 
care-cost protected even though the provider was out-of-network. You say that if you would have known there 
was a copayment of $100 per session, you would have reduced the duration of your treatment. 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 a $100 
copayment for in-network and out-of-network mental health services provided at an outpatient hospital.  
 
 
  You have been asked to pay a total of $2,600 for mental health services ($100 copayment x 26 sessions = 
$2,600). Mental health services fall within the Outpatient Mental Health Care 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 copayments for mental health services provided from March 3, 2022, to May 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on December 22, 2021. 
 
You asked the Plan to pay for code 83789. 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 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. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on December 22, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the duplex scan of aorta, inferior vena cava, iliac vasculature, or 
bypass grafts (93978). 
 
You asked the Plan to pre-approve the duplex scan. You say that you have included detailed information to 
support the medical necessity and reasons why this authorization denial should be reconsidered. The Plan 
denied your request. The Plan says that the records do not support that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the duplex scan. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the requesting physician is a vascular specialist and has written a valid letter of appeal 
explaining the reasoning for the requested tests. Based upon that letter of explanation the requested ultrasound 
exams should be approved. 
 
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 duplex scan have been met. Therefore, we decided that the Plan has to pre-
approve the duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts (93978).  
 
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 core buildup (D2950), and a crown (D2740) provided from 
June 10, 2021, through August 10, 2021. 
 
You asked the Plan to pay for a core buildup and a crown. You say that you thought the provider was in-
network. The Plan denied your request. The Plan says the services at issue 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. Therefore, we decided that the Plan does not have to pay for a core 
buildup (D2950), and a crown (D2740) provided from June 10, 2021, through August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that your agent told you these services would be covered. 
The Plan denied your request. The Plan says a complete maxillary denture (D5110) and a partial mandibular 
denture (D5214) are not covered by your supplemental 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 pre-approve a 
complete maxillary denture (D5110) and a partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to cover the services. 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 June 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 88360 is not supported. 
 
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, the CPT Code Manual definition of code 88360 is morphometric analysis, tumor 
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, per specimen, each single antibody stain procedure; manual. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, there is no documentation of 
manual morphometric analysis. 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 pay for the laboratory 
services rendered on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), and teeth 
cleaning (D1110), and does not have to pay for a panoramic radiographic image (D0330) provided on May 16, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider was in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. Additionally, 
panoramic radiographic images are 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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, panoramic radiographic images are not a covered benefit. Therefore, we decided that the Plan 
does not have to pay more for a comprehensive oral evaluation (D0150), and teeth cleaning (D1110), and does 
not have to pay for a panoramic radiographic image (D0330) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, extra link for link 
headrest (K0108), a wheelchair component or accessory, joystick module (K0108), a power wheelchair 
accessory, expandable controller (E2377), a power wheelchair accessory, harness for upgrade to expandable 
controller (E2313), an arm gel pad right (K0108), an arm gel pad left (K0108), a programing key for R net 
(K0108) and an output Module R-net control system (K0108). 
 
 
 
 
 You asked the Plan to pre-approve wheelchair components and accessories. You say that the enrollee needs 
more than one power seat option, tilt and recline. She requires power recline to assist with completing pressure 
reliefs in combination with the power tilt. She also has underlying trunk tone related to her brain injuries. She 
needs to be able to adjust the seat to back angle relative to her changes in tone. Due to her limited 
trunk strength and stability, she does require this system. The Plan denied your request. The Plan says the 
enrollee does not show Medicare criteria coverage for the requested accessories/components. 
 
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 wheelchair components and 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found provided records document that the enrollee has 4-/5 right 
upper extremity strength and is independent with upper and lower body dressing thus indicating she has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches, thus the expandable controller, harness and electronic connection do not meet Medicare criteria for 
coverage. The extra link for link headrest, joystick module, programing key for R net and output module R-net 
control system are already included in items requested or approved. the provided medical records do not 
document a need for the arm gel pad right and arm gel pad left as opposed to standard pads. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair components and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair component or accessory, extra link for link 
headrest (K0108), a wheelchair component or accessory, joystick module (K0108), a power wheelchair 
accessory, expandable controller (E2377), a power wheelchair accessory, harness for upgrade to expandable 
controller (E2313), an arm gel pad right (K0108), an arm gel pad left (K0108), a programing key for R net 
(K0108) and an output Module R-net control system (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service February 21, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that this service is supported as billed. The 
Plan denied your request. The Plan says they have agreed to pay for the drug testing; however, this service is 
not separately payable. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service April 11, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported as billed. 
The Plan denied your request. The Plan says they have agreed to pay for the drug testing; however, this service 
is not separately payable. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay 
because of the rescheduling of your appointment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $475 
copayment for a non-surgical visit in an outpatient clinic.  
 
You have been asked to pay the allowed amount of $136.14, which is less the applicable copayment amount for 
a non-surgical visit in an outpatient clinic. The office visit falls within the Outpatient Hospital 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 office visit provided on April 20, 2022.