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

 
We decided that the Plan does not have to reimburse you for the root canal (D3330) provided on September 9, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that you tried to make appointments with 
in network providers. You say that no one would answer your phone calls. You say that you were advised the 
provider in this case was in network. You also say that you should be reimbursed. The Plan denied your 
request. The Plan says dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse 
you for the root canal (D3330) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on August 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had your teeth cleaned and x-rays. You say 
that you have a dental allowance of $325 for dental maintenance procedures. You also say that your spouse had 
the same services done and it was fully approved. The Plan denied your request. The Plan says routine dental 
services are not covered by Medicare or the Plan. 
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 the comprehensive oral 
evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for the filling (D2335) provided on March 
11, 2021. 
 
You asked the Plan to reimburse the copayment for the dental service. You say that your agent advised since 
you have $1,000 of dental coverage, you should not have been charged $20 for the filling. You say that you had 
not yet received $1,000. You also say that you should be refunded $20. The Plan denied your request. The Plan 
says there is a $20 copayment that applies for restorative service, including fillings. 
 
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, there is a $20 copayment that applies 
to restorative services. This is a contractual obligation you agreed to when you enrolled in the Plans dental 
coverage. Therefore, we decided that the Plan does not have to reimburse the copayment for the filling (D2335) 
provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056 x 2), implant 
supported crown (D6065 x 2), and pontics (D6241 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your teeth and cannot eat. The 
Plan denied your request. The Plan says dental implant and all associated services are excluded from coverage. 
 
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 implant and all 
associated services are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve a prefabricated abutment (D6056 x 2), implant supported crown (D6065 x 2), and 
pontics (D6241 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided 
November 15, 2021. 
 
You asked the Plan to pay for the additional intraoral x-rays and 2D oral/facial photographs. You say that you 
would like these services covered. The Plan denied your request. The Plan says the 2D photographs are not 
covered under your benefits and you have exceeded the frequency limit for the intraoral x-rays. 
 
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 one intraoral 
x-ray per calendar year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray was covered on the same date of service Based on this information, we decided that the Plan's frequency limit 
for coverage of the additional intraoral x-rays has been exceeded. Though the Plan offers dental benefits in 
excess of Medicare coverage, the 2D oral/facial photographs are not among those covered services. Therefore, 
we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided 
November 15, 2021.  
 
Your complaint about your varied experiences with the dental plan is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified removable prosthodontic procedure (D5899) 
provided on March 11, 2021. 
 
You asked the Plan to pay for unspecified removable prosthodontic procedure. You say that there was 
confusion when you were told you needed a complete set of dentures. You had all your teeth pulled out and 
then told that you could not have two dental policies. You are on a limited income and would like the Plan to 
pay for this service. The Plan denied your request. The Plan says the requested service is not listed as a covered 
benefit with your Plan. The Plan also says that they contacted the dental office and they explained you were 
made aware of the non-covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
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 
unspecified removable prosthodontic procedure (D5899) provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, pelvic (nonobstetric), real time with image 
documentation; complete (76856) provided on June 30, 2021. 
 
You asked the Plan to pay for the complete ultrasound. You say that these services were medically necessary 
and were billed in accordance with Medicare regulations. The Plan denied your request. The Plan says the 
service at issue is not supported as billed and is best described by procedure code 76857. 
 
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 76856 is ultrasound, pelvic (nonobstetric), real time with 
image documentation; complete. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the complete ultrasound. Our reviewer says that the 
documentation does not support this service as billed. Our reviewer found that the submitted procedure report documents a limited study. The report states, there is no previous pelvic ultrasound available for comparison. 
This is a limited study". In this case, a complete study cannot be verified. Therefore, the billing for a complete 
ultrasound is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the complete ultrasound have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound, pelvic (nonobstetric), real time with image documentation; complete 
(76856) provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, 
expandable controller harness and a power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that the member's upper limb strength and function are adequate for the 
member to be able to control the power options using their own switches which are included in the allowance 
of these power options.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it 
is not primarily medical in nature. 
 
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 these items. Our reviewer says that the 
expandable controller, electronic connection and expandable controller harness are not considered medically 
reasonable and necessary in this case. The expandable controller, electronic connection and expandable 
controller harness are not medically necessary as the enrollee does have use of her right upper extremity and 
can operate and control the power options using the switches that are included in the basic wheelchair. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller, electronic connection, expandable controller harness and a 
power seat elevation feature for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants 
(D6010) provided November 1, 2021. 
 
You asked the Plan to pay for the endosteal implants. You say that this was medically necessary surgery and 
should be covered. 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 
surgical placement of implant body: endosteal implants (D6010) provided November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate mandibular denture (D5140), simple 
extractions (D7140), surgical extractions (D7210), and alveoloplasties in conjunction with extractions (D7310) 
provided on July 20, 2021. 
 
You asked the Plan to pay for the immediate mandibular denture, simple extractions, surgical extractions, and 
alveoloplasties. You say that these services should be paid as part of your medical policy for the treatment of 
your lymphoma cancer. The Plan denied your request. The Plan says these services are not covered expenses 
under your dental plan. 
 
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 the 
immediate mandibular denture (D5140), simple extractions (D7140), surgical extractions (D7210), and 
alveoloplasties in conjunction with extractions (D7310) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the neurology visit. You say that you were referred to this physician because 
he specializes in your health condition. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The records provided for review do not show that the service at 
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the neurology 
visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional mileage for routine transportation. 
 
You asked the Plan to provide coverage for additional mileage for routine transportation. You say that you only 
want to see the requested provider who is 53 miles away from your home. The Plan denied your request. The 
Plan says this request is not covered by the health Plan because it will exceed your benefit mileage limit of 50 
miles. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. 
 
We looked at your request, the records in the case file, and the rules. The file shows that the shortest route to 
your providers office is 52 miles. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to provide 
coverage for additional mileage for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spectrometry testing (83789) provided on September 27, 2021. 
 
You asked the Plan to pay for spectrometry testing. You say that this is supported in the records. The Plan 
denied your request. The Plan says this should not be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed.  
We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this 
testing was performed as validity testing for the specimen used for drug testing. Based on this information, we 
decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that 
the Plan does not have to pay for spectrometry testing (83789) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The provided records 
did not show instability or high risk history to suggest a need for an extended hospital recovery for this 
typically ambulatory and low-risk procedure. There was no documented expectation that the patient would 
require hospital services that would likely cross 2 midnights. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested dental service is 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 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 pre-approve 
removal of torus mandibularis (D7473) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1/BRCA2 genetic testing. 
 
You asked the Plan to pre-approve BRCA1/BRCA2 genetic testing. You say that it is not your fault that the 
physician submitted the information incorrectly. You say that your mom had breast cancer and your dad had 
leukemia. You say that it was put in the system wrong and that you cannot get leukemia genetically. You say 
that your mom had breast cancer and that is genetic, which is why you need the requested testing done. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is non-covered 
for the testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. 
 
We looked at the file and Medicare rules. While the records demonstrate that you have a family history of 
breast cancer, there is no evidence that you yourself have a personal history of breast, ovarian, fallopian tube, 
primary peritoneal, pancreatic, or prostate cancer Based on this information, we decided that Medicare rules for 
coverage of BRCA1/BRCA2 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA1/BRCA2 genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete mandibular denture (D5751) 
provided on May 5, 2021. 
 
You asked the Plan to pay for the reline of a complete mandibular denture. You say that when you were told 
you would have to pay $500 for this service, you told them to cancel the appointment because you could not 
afford to pay that. The Plan denied your request. The Plan says your benefits for this service have been satisfied 
and the frequency limitation has been exceeded. 
 
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, denture reline is limited to one 
procedure code per calendar year. The record shows that you received a reline of a complete maxillary denture 
(D5750) on May 5, 2021 and your denture reline benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the reline of a complete mandibular denture (D5751) provided on May 5, 2021.
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 December 7, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you have not had a comprehensive 
exam before. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
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. The Plan covers the 
comprehensive oral exam once every 36 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam was previously covered on December 9, 2019. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided December 7, 2021.