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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and periodontal 
maintenance (D4910) provided on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believed 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 periodontal maintenance (D4910) provided on March 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal hook accessory (K0108) for a wheelchair. 
 
You asked the Plan to pre-approve a personal hook. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal hook accessory (K0108) for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81407, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's 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 
March 21, 2022 billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 
0033U, 81407, and 81238.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you were receiving deep cleanings every 6 
months under your previous employer insurance. You also say that due to the pandemic and your previous 
dentist retiring, you have not been to the dentist since 2018. The Plan denied your request. The Plan says 
scaling and root planing is not listed as 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, the requested scaling and root planing 
for all 4 quadrants are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound vac services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve wound vac services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
wound vac services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), panoramic x-ray (D0330), and 
bitewing x-rays (D0274) provided on March 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have gone to this dentist for five years. You 
say that the dental office did not inform you that they no longer accepted your plan. You also say that you did 
not know that you needed to call the dental plan before going. 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 dental services are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the oral exam (D0120), panoramic x-ray (D0330), and bitewing x-rays (D0274) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026), and acupuncture services 
(97810, 97811) provided from October 25, 2021, to December 23, 2021. 
 
You asked the Plan to pay for the infrared therapy. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says infrared therapy is not considered medically reasonable 
or necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for the infrared therapy (97026), and acupuncture services (97810, 97811) provided from October 25, 2021, to 
December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #7 and 8 (D7140) provided on April 13, 2022. 
 
You asked the Plan to pay for extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says extractions (D7140) are not covered by your preventive dental 
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 
extractions of tooth #7 and 8 (D7140) provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 23, 2021. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on July 
23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported crown (D6066) and custom fabricated 
abutment (D6057) provided on December 27, 2021. 
 
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 an implant supported crown (D6066) and custom fabricated 
abutment (D6057) 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 an 
implant supported crown (D6066) and custom fabricated abutment (D6057) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0150) provided by a network 
provider on April 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told by an insurance agent that this was 
a covered service. 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 the periodic oral evaluation (D0150) provided by a network provider on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the after-cataract laser surgery to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the after-cataract laser surgery. You say that are appealing the denial of this 
service. 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 after-cataract laser surgery. We found no exception that would require the Plan 
to pre-approve the after-cataract laser surgery. Therefore, we decided that the Plan does not have to pre-
approve the after-cataract laser surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) provided on 
March 29, 2022. 
 
You asked the Plan to pay for x-rays. You say that this service was needed to meet surgery requirements. The 
Plan denied your request. The Plan says that an intraoral complete x-ray series (D0210) 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 an 
intraoral complete x-ray series (D0210) provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, fish), urinary tract 
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (88120) provided 
February 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. The Plan denied your request. The Plan says 88120 is not a Medicare benefit for the diagnosis listed 
on the claim and is done for screening purposes. 
 
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 service, 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 cytopathology, in situ hybridization (eg, fish), urinary tract specimen with morphometric analysis, 3-5 
molecular probes, each specimen; manual (88120) provided February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the free soft tissue graft procedures (D4277) and (D4278) 
provided on January 25, 2022. 
 
You asked the Plan to pay for free soft tissue graft procedures (D4277) and (D4278). You say that you are 
requesting that the appeal denial for services provided be overturned for coverage. The Plan denied your 
request. The Plan says the services received are non-covered Medicare. 
 
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 free soft 
tissue graft procedures (D4277) and (D4278) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic 
imaging (D0330), and an extraction (D7140), provided by a participating provider on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist because you had an 
infection in your body and a severe migraine headache. 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 January 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
panoramic imaging (D0330. An extraction (D7140) was approved with a $25 copayment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on March 24, 2021, and 
intraoral x-rays (D0210) and fluoride varnish (D1206) provided on March 31, 2021. We also decided that the 
Plan does not have to waive the coinsurance for periodontal maintenance (D4910) and fluoride varnish 
(D1206) provided on July 28, 2021. 
 
You asked the Plan to pay for x-ray and fluoride. You also asked the Plan to waive the coinsurance for 
periodontal maintenance and fluoride. You say that these services should be covered at 100%. The Plan denied 
your request. The Plan says the claims for dates of service March 24, 2021, and March 31, 2021, were submitted 
untimely and not covered. The Plan also says that you have been charged the correct cost sharing 
amount for services received on July 28, 2021. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for x-rays and fluoride provided from March 24, 2021, to March 31, 2021, was 
not filed until April 2, 2022. This means that more than one calendar year from the date of service had passed 
before a claim was filed.  
 
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 75% 
coinsurance for out-of-network periodontal maintenance. The contract also says that enrollees must pay 50% 
coinsurance for out-of-network fluoride varnish. 
 
You have been asked to pay $15, which is 75% coinsurance of the allowed amount for periodontal maintenance 
provided on July 28, 2021 ($20 allowed amount x 75% coinsurance = $15). You have also been asked to pay 
$1, which is 50% coinsurance of the allowed amount for fluoride varnish provided on July 28, 2021 ($2 
allowed amount x 50% coinsurance = $1). Periodontal maintenance and fluoride fall within the Dental Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on March 24, 
2021, and intraoral x-rays (D0210) and fluoride varnish (D1206) provided on March 31, 2021. We also decided 
that the Plan does not have to waive the coinsurance for periodontal maintenance (D4910) and fluoride varnish 
(D1206) provided on July 28, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is clinically indicated (i.e., medical necessity 
criteria will be met) when highly conformal dose planning is required. 
 
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 IMRT. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the 2022 guidelines now state that IMRT 
is preferred for reirradiation of previously treated patients with recurrent disease, patients treated 
postoperatively due to increased acute or late toxicity or in unique anatomical situations (eg, coverage of 
external iliac or inguinal lymph nodes or avoidance of small bowel.  These situations do not seem to apply to 
this enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on December 2, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-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 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 subsequent nursing facility care provided on 
March 15, 2022, by an out-of-network (OON) provider.