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

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) and an 
extraction of tooth #17 (D7210) provided on March 4, 2022. 
 
You asked the Plan to pay for adjunctive procedure and an extraction. You say that this should be covered as 
any other operation in a medical facility would be covered. The Plan denied your request. The Plan says an 
unspecified adjunctive procedure (D9999) and an extraction (D7210) are not covered by your routine 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 an 
unspecified adjunctive procedure (D9999) and an extraction of tooth #17 (D7210) provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on October 5, 2021. 
 
You asked the Plan to pay for the general health panel. You say that you would like this claim reprocessed per 
the medical records. The Plan denied your request. The Plan says this code is not eligible for payment based on 
Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic cardiovascular screening testing (81479) 
provided October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says the cardiovascular screening/risk assessment panel does not meet the Medicare coverage 
criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the genetic cardiovascular screening testing (81479) provided October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81238, 81220, 81226, 81335, 81230, 81227, 
81355, 81241, 81291, and 81240 provided on September 10, 2021. 
 
You asked the Plan to pay for procedure codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 
81291, and 81240. 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for procedure codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291, and 81240 
provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (81206, 81210, 81235, 
81272, 81275, 81276, 81292, 81301, 81311 and 81321) provided on June 15, 2021. 
 You asked the Plan to pay for the laboratory service. You say that the test is a medically necessary and valuable 
tool when determining appropriate medical treatment to potentially impact the enrollee's overall survival. The 
Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the molecular pathology testing (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 
81311 and 81321) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on May 4, 2021, by 
the out-of-network provider. 
 
You asked the Plan to pay for the dental service. You say that you did not know that the provider was out-of-
network. You say that the in-network providers you contacted were not available. You also say that had you 
known the provider was out-of-network you would not have used them. 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 surgical extraction is 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 surgical extraction (D7210) provided on May 4, 2021, by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 special 
anesthesia service rendered on January 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection at an additional level, represented by 
code 64484. 
 
You asked the Plan to pre-approve the epidural steroid injection at an additional level. You say that the records 
provided support the need for the injection services at an additional level. You say that they have changed the 
level and location of the injection to address alternate pathology on the enrollee's magnetic resonance imaging 
(MRI), so the enrollee's response to the prior injections is not a valid denial reason. The Plan denied your 
request. The Plan says that the requested services are not reasonable and necessary. 
 
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 epidural steroid injection at an 
additional level. Our reviewer says that the requested epidural steroid injection services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low 
back and lumbar radiculopathy. He has S1 Epidural Steroid injection and obtained some relief. His MRI shows 
pathology at L4 and L5. The request is for Epidural Steroid injections at different levels/a different approach 
than before. A repeat Epidural Steroid injection is permitted if the first did not provide adequate relief if a 
different approach is undertaken. 
 
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 epidural steroid injection at an additional level have been met. Therefore, 
we decided that the Plan has to pre-approve an epidural steroid injection at an additional level, represented by 
code 64484. 
   
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 limited oral evaluation (D0140), intraoral-periapical x-ray 
(D0220), and tooth re-implantation (D7270) provided on January 8, 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 you do not have routine dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140), intraoral-periapical x-ray (D0220), and tooth re-implantation (D7270) provided on January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and topical application of 
fluoride varnish (D1206) provided on August 4, 2020, and periodontal maintenance (D4910) provided on 
November 4, 2020. 
 
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 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 limited oral evaluation (D0140) and topical application of fluoride varnish (D1206) provided on 
August 4, 2020, and periodontal maintenance (D4910) provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling (D2331), a crown (D2740), 
and core build up (D2950) provided on June 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you were having this 
procedure done. You also say that you thought you were only getting a filling. The Plan denied your request. 
The Plan says a resin-based composite filling (D2331), a crown (D2740), and core build up (D2950) 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 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 resin-
based composite filling (D2331), a crown (D2740), and core build up (D2950) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the limited oral evaluation - problem focused (D0140) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210) provided February 8, 2022, up to the Plans $250 limit. 
 
You asked the Plan to pay for the limited oral exam and tooth extraction. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that this service is not covered under your 
medical plan. 
 
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 limited 
oral exam and tooth extraction up to a $250 limit. 
 
We looked at the file and Medicare rules. The Evidence of coverage states that oral exams and extractions are 
covered by the Plan. The Plan has not provided any documentation to indicate that the $250 limit for dental 
coverage had been exceeded prior to the services being rendered. Based on this information, we decided that 
the Plan's rules for coverage of the limited oral exam and tooth extraction have been met. Therefore, we 
decided that the Plan has to pay for the limited oral evaluation - problem focused (D0140) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210) provided February 8, 2022, up to the Plans $250 limit.  
 
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 intraoral x-rays (D0210) and 2D facial x-rays (D0350 x 4) 
provided on February 15, 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 benefit for intraoral x-rays has already been exhausted. The 
Plan also says that 2D facial x-rays 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 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 intraoral x-rays was exhausted on date of service September 20, 2019. 2D facial x-rays 
are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral x-rays 
(D0210) and 2D facial x-rays (D0350 x 4) provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the requested bone marrow aspirate 
(20939) is not medically reasonable and necessary. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed before 
coverage can 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodontal maintenance (D4910) provided on March 3, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that this service was medically necessary, and 
it should be paid at the higher rate. The Plan denied your request. The Plan says that this service was processed 
under the alternative benefit. 
 
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. The Plan did not provide medical records to show if there was a history of 
periodontal maintenance within the last 24 months. Without the medical records we are unable to determine if 
the alternative benefit would produce a satisfactory result. Therefore, we decided that the Plan has to pay for 
periodontal maintenance (D4910) provided on March 3, 2022.  
 
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 pre-approve an office visit with an out-of-network (OON) dentist. 
 
You asked the Plan to pre-approve the dental services. You say that you broke your tooth and you need to be 
seen as soon as possible. The requested provider is your dentist, and you would like to continue to see him. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve an office 
visit with an out-of-network (OON) dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core build up (D2950), a crown (D2740), and a resin-
based composite filling (D2391) provided on January 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should not be responsible for such a 
large amount. 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. 
 
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 core build up (D2950), a crown (D2740), 
and a resin-based composite filling (D2391) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) and a panoramic x-ray (D0330) 
provided on February 1, 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 benefit for a panoramic x-ray has already been exhausted. 
Cone beam imaging is not covered by your dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a panoramic x-ray was exhausted on date of service April 16, 2019. Cone beam imaging 
is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam 
imaging (D0364) and a panoramic x-ray (D0330) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need to have a tooth extracted and the 
dentist needed to perform an exam. 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 8, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
February 9, 2022.