Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of long term acute care hospital (LTACH) 
services. 
 
You asked the Plan to pre-approve the continuation of LTACH services. You say that the continued LTACH 
care is medically necessary. The Plan denied your request. The Plan says the continued LTACH care is not 
medically necessary. 
 
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 continued LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee does not require continued 
LTACH care. 
 
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 continuation of long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110), bitewing x-rays (D0274), and a 
periodic oral evaluation (D0120), and to pay for periapical x-rays (D0220, D0230) provided on April 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider told you they were in-
network and services should be covered at 100%. 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. 
 
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, periapical x-rays (D0220, D0230) are 
not among those covered under this benefit. You have been asked to pay 30% coinsurance for prophylaxis 
(D1110), bitewing x-rays (D0274), and a periodic oral evaluation (D0120).  
 Code Billed Amount Allowed Amount 30% Coinsurance Total Responsibility 
D1110 $101 $94 $28.20 $35.20 
D0274 $68 $68 $20.40 $20.40 
D0120 $51 $51 $15.30 $15.30 
 
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. 
Therefore, we decided that the Plan does not have to pay more for prophylaxis (D1110), bitewing x-rays 
(D0274), and a periodic oral evaluation (D0120), and to pay for periapical x-rays (D0220, D0230) provided on 
April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 11, 2021 billed with 
codes 81185, 81201, 81317, 81403, 81404, 81405, 81406, 81432, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 11, 2021 billed with codes 81185, 81201, 81317, 81403, 81404, 81405, 81406, 81432, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 13, 2022, and maxillary partial denture (D5213) and mandibular partial denture (D5214) 
provided on January 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 13, 2022, and 
maxillary partial denture (D5213) and mandibular partial denture (D5214) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic x-
ray (D0330) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on May 17, 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), and prophylaxis (D1110) provided on April 20, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression that the treating 
provider was in the Plan's network, otherwise, you would have gone elsewhere. The Plan denied your request. 
The Plan says the dental services were received from an OON provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 20, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from November 30, 2021, through 
January 12, 2022. 
  You asked the Plan to pay for acupuncture. You say that acupuncture is a covered benefit under their policy, 
and you pursued coverage after this verification. You say that the dates of service should be reprocessed to 
honor the benefits. The Plan denied your request. The Plan says auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, this provider is not a covered provider type for 
acupuncture. Therefore, we decided that the Plan does not have to pay for acupuncture provided from 
November 30, 2021, through January 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on March 9, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for ambulance services. You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for ambulance services provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for periodontal scaling and root planing (D4342 
x 2) provided on March 10, 2022. 
 
You asked the Plan to waive the cost share for periodontal scaling. You say that you do not understand why the 
claim is getting denied. The Plan denied your request. The Plan says your annual allowance 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 the enrollee is responsible 
for any amount over and above the allowance amount.  
 
The record shows you have exhausted your annual allowance for dental services during the processing of this 
claim, and you are responsible for any amount over the allowance amount.  Periodontal scaling falls 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 periodontal scaling and root 
planing (D4342 x 2) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899) provided February 17, 2022. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure. You say that you do not 
understand why this is not covered under your dental insurance. The Plan denied your request. The Plan says 
this service is 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 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 
unspecified removable prosthodontic procedure, by report (D5899) provided February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 4, 2021 billed with 
codes 81206, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 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 
May 4, 2021 billed with codes 81206, 81301, and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274), resin-based filling on tooth #17 
(D2392), a crown on tooth #19 (D2740), and 2D oral x-ray (D0350) provided on January 18, 2022, and resin-
based fillings on tooth #7, 8, and 10 (D2330) provided on February 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your quarterly allowance for comprehensive dental services has 
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. 
 
 The record shows your quarterly allowance for comprehensive dental services have been exhausted. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among 
those covered when the quarterly allowance has been exhausted. Therefore, we decided that the Plan does not 
have to pay for bitewing x-rays (D0274), resin-based filling on tooth #17 (D2392), a crown on tooth #19 
(D2740), and 2D oral x-ray (D0350) provided on January 18, 2022, and resin-based fillings on tooth #7, 8, and 
10 (D2330) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental evaluation and procedures (D0120, D0274 D2330, 
D2391, D4910) provided from December 6, 2021, to December 13, 2021. 
 
You asked the Plan to pay for the dental evaluation and procedures. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
evaluation and procedures (D0120, D0274 D2330, D2391, D4910) provided from December 6, 2021, to 
December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external bleaching for home (D9975) provided on February 
3, 2022. 
 
You asked the Plan to pay for external bleaching. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says external bleaching for home (D9975) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for external 
bleaching for home (D9975) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft (D4263) and osseous surgery (D4261) 
provided on February 11, 2022, by the opt-out provider, and periodontal maintenance (D4910) provided on 
March 3, 2022, by the in-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression that the services 
would be covered per the plan representative that you spoke with before signing up. The Plan denied your 
request. The Plan says dental services rendered by a provider that has opted out of Medicare are not payable. 
The Plan also says that periodontal maintenance 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, services performed by an opt-out 
provider are not covered. Additionally, the bone graft, osseous surgery and periodontal maintenance are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
graft (D4263) and osseous surgery (D4261) provided on February 11, 2022, by the opt-out provider, and 
periodontal maintenance (D4910) provided on March 3, 2022, by the in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of a dental implant (D6100), osseous surgery 
(D7950), and tissue regeneration (D4266) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the removal of a dental implant (D6100) and tissue regeneration 
(D4266) were received from an out-of-network provider and are not covered by your supplemental benefits. 
The Plan also says that osseous surgery (D7950) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the removal of a dental implant (D6100) and tissue 
regeneration (D4266) are not covered under this benefit when received from an out-of-network provider. 
Osseous surgery (D7950) is not covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the removal of a dental implant (D6100), osseous 
surgery (D7950), and tissue regeneration (D4266) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), consultation (D9310), 
and pulp vitality tests (D0460) provided from February 23, 2022 to March 12, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you feel you should not have to pay 
any other charges because you had been referred to the dentist. The Plan denied your request. The Plan says 
neither you nor the provider contacted the Plan about your coverage benefits or the provider's status. The Plan 
also says that the pulp vitality test is not a covered benefit, and services done by an out-of-network 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 Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, you pay a 20 percent coinsurance for 
covered basic dental services after the $100 annual deductible. The record shows that as of February 23, 2022, 
you had not met the $100 deductible, and the $76 charge applied toward the deductible. The contract also does 
not list pulp vitality tests as a covered benefit, and services rendered by an OON provider are not covered. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), consultation 
(D9310), and pulp vitality tests (D0460) provided from February 23, 2022 to March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 
22, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that the provider never advised this 
service would not be covered. 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 re-
cement or re-bond crown (D2920) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950 x 3), retainer crowns (D6740 x 3), and 
gingival irrigation (D4921 x 2) provided on October 8, 2021, gingival irrigation (D4921 x 2) provided on 
October 11, 2021, and core build up (D2950) and a crown (D2740) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that these services 
were covered. The Plan denied your request. The Plan says your benefit for core build up and crowns have 
already been exhausted. The Plan also says that retainer crowns and gingival irrigation are not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 core build up was exhausted on date of service October 8, 2021. The record also shows 
your benefit for a crown was exhausted on date of service November 4, 2021. Retainer crowns and gingival 
irrigation is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
build up (D2950 x 3), retainer crowns (D6740 x 3), and gingival irrigation (D4921 x 2) provided on October 8, 
2021, gingival irrigation (D4921 x 2) provided on October 11, 2021, and core build up (D2950) and a crown 
(D2740) provided on November 4, 2021.