Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home care services (skilled nursing visits 
(13), home health aide visits (13), physical therapy visits (5), and occupational therapy visits (2)). 
 
You asked the Plan to pre-approve the home health care services. You say that you have osteo mellitus 
infection in the bone in your left foot that is being treated by a nurse, infectious disease and podiatrist. You state that you are totally incontinent and has difficulty getting to the bathroom on your own and are having 
extreme difficulty with your mobility. The Plan denied your request. The Plan says the services are not 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care services. Our 
physician reviewer found the documentation does not support that you require additional skilled nursing 
services or skilled rehabilitation services to provide treatment that is medically necessary. You do not require 
additional skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in 
order to improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. 
 
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 home health care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional home care services (skilled nursing visits (13), home health aide 
visits (13), physical therapy visits (5), and occupational therapy visits (2)).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal maintenance (D4910) provided on March 
21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this service should be covered at 100%. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-
sharing amount when your services are received from an out-of-network provider. The Plan says you have been 
charged the correct cost sharing amount. 
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 periodontal maintenance (D4910) provided 
on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral x-rays (D0230 x 3) provided on March 
28, 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 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 intraoral x-rays was exhausted on the same date of service March 28, 2022. 
Therefore, we decided that the Plan does not have to pay for additional intraoral x-rays (D0230 x 3) provided 
on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical-additional radiographic image 
(D0230) provided on March 15, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the benefit for this service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service March 15, 2022. The Plan 
provides coverage of this service once per calendar year. The Plan issued payment for an intraoral periapical-
first radiographic image (D0220) that was provided on the same day; therefore, the benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the intraoral periapical-additional radiographic 
image (D0230) provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrodes (A4556) and lead wires (A4557), miscellaneous 
surgical supplies (A4649), a monitoring device (A9279), an intravenous tubing extension set (S1015), infection 
control supplies (S8301) and additional supplies, materials and clinical staff time (99072) provided on February 
4, 2022. 
 
You asked the Plan to pay for electrodes and lead wires, surgical supplies, monitoring device, intravenous 
tubing, infection control supplies and additional resources. You say that the items/services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 codes A4556, A4557 and A4649 have a status indicator of P on the Physician Fee Schedule. 
CPT code 99072 has a status indicator of B. This means that CPT codes A4556, A4557, A4649 and 99072 are 
not separately payable. CPT codes A9279, S1015 and S8301 have a Status Indicator of I. This means that CPT 
codes A9279, S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided 
that Medicare rules for coverage of electrodes and lead wires, surgical supplies, monitoring device, intravenous 
tubing, infection control supplies and additional resources have not been met. Therefore, we decided that the 
Plan does not have to pay for electrodes (A4556) and lead wires (A4557), miscellaneous surgical supplies 
(A4649), a monitoring device (A9279), an intravenous tubing extension set (S1015), infection control supplies 
(S8301) and additional supplies, materials and clinical staff time (99072) provided on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on February 
28, 2022. 
 
You asked the Plan to waive the deductible for laboratory services provided on February 28, 2022. You say 
that the cost share has been incorrectly applied and these services were part of your annual physical. The Plan 
denied your request. The Plan says the cost share has been correctly applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time this claim was processed. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81220, 81226, 81227, 
81230, 81240, 81241, 81291, 81335, 81355 and 81479 provided April 20, 2021. 
 You asked the Plan to pay for the laboratory services. You say that please review the attached medical records 
and consider towards the payment. 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, we find that CPT code 81220, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 
81479 is not supported in the medical record. Specifically, if one laboratory procedure evaluates multiple genes 
using a next generation sequencing 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 CPT code. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded as 81220, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 
81479 provided April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for inhalation of nitrous oxide (D9230), a limited oral 
evaluation (D0140), periapical x-rays (D0220), and an extraction (D7210) provided on February 14, 2022. 
 
You asked the Plan to pay more for the dental services. The Plan denied your request. The Plan says the 
enrollee is responsible for any charged amount above the Plan's cost-sharing amount when the 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 Plan's coverage rules apply in this case. 
 
The enrollee has been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 inhalation of nitrous oxide (D9230), a 
limited oral evaluation (D0140), periapical x-rays (D0220), and an extraction (D7210) provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental when used as bone graft material. More research is needed. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the building up of anatomical crown (code D2950) for tooth 
#23 and #26 and for a crown - porcelain/ceramic substrate (code D2740) for tooth #23 and #26 provided on 
April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were covered before and werent notified of 
any changes. 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 building up of anatomical crown (code D2950) for tooth #23 and #26 and for a crown - 
porcelain/ceramic substrate (code D2740) for tooth #23 and #26 provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer screening tests coded as 81314, 81317, 
81334, 81351, 81407, 81408 and 81435 provided April 23, 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 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, we find that CPT codes 
81314, 81317, 81334, 81351, 81407, 81408 and 81435 are not supported 
in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a 
patient in parallel. If a laboratory assays two or more genes in a patient in parallel, then those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS 
code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage 
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hereditary cancer screening tests coded as 81314, 81317, 81334, 81351, 81407, 81408 and 81435 provided 
April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and three (3) extractions (D7210) 
provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you have a cyst in your gums that is pushing 
on your sinuses, and you need the extractions done immediately. The Plan denied your request. The Plan says 
consults and dental services provided by Oral Surgeons, Periodontists, Prosthodontists, other dental specialists, 
or non-network General Dentists 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. The Plan covers dental 
services when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Specifically, dental services must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation 
and three (3) extractions (D7210) provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to provide coverage for guided tissue regeneration - resorbable barrier, per site 
(D4266) and bone replacement graft for ridge preservation - per site (D7953) provided September 15, 2021, 
according to your 2021 coverage benefits. 
 
You asked the Plan to provide coverage for the guided tissue regeneration and bone replacement graft. You say 
that you attempted to have the services authorized and have received confusing denials for the services. The 
Plan denied your request. The Plan says that these services are not covered under your benefits. 
 
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. In this case the Plans denial explanation presented in the case file is based on 
exclusions cited in the 2022 Evidence of Coverage. The list of excluded services provided in the case file is for 
2022 as well. The Plan has not provided documentation which verifies that the services at issue were excluded 
from the enrollees coverage at the time they were provided in accordance with 2021 benefits. The 2021 
Evidence of Coverage indicates that oral surgery services are covered with 50% coinsurance up to a yearly 
maximum of $800. Therefore, we decided that the Plan has to provide coverage for guided tissue regeneration - 
resorbable barrier, per site (D4266) and bone replacement graft for ridge preservation - per site (D7953) 
provided September 15, 2021, according to your 2021 coverage benefits.  
 
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 dental services provided on November 9, 2021 to December 
21, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told by the provider that they will submit 
your claims as an in-network provider. You say that all your claims were processed as out-of-network. You say 
you feel you should be refunded back. The Plan denied your request. The Plan says the requested service is 
available within an in-network Plan facility. 
 
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, when services are obtained from an 
out-of-network dentist the Plan only pays up to a certain amount. You are responsible for any amount beyond 
with the Plan pays. Therefore, we decided that the Plan does not have to pay for dental services provided on 
November 9, 2021 to December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard  soft appliance, full arch (D9945) 
provided January 5, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that you need this service to limit further damage to 
your teeth. 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 
occlusal guard  soft appliance, full arch (D9945) provided January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns on tooth #8, 9, and 10 (D2740) provided on February 
24, 2022. 
 
You asked the Plan to pay for the crowns. You say that the crowns are medically necessary. The Plan denied 
your request. The Plan says crowns are only covered when there is extensive loss of tooth structure due to 
caries and/or fracture. 
 
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 crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the documentation does not indicate a 
significant coronal breakdown due to caries or fracture to warrant crown restorations (D2740) for tooth # 8, 9 
and 10. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pay for crowns on tooth #8, 9, and 10 (D2740) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal adjustment (D2740) provided by a participating 
provider on November 3, 2021. 
 
You asked the Plan to pay for an occlusal adjustment. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the denied 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 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 
occlusal adjustment (D2740) provided by a participating provider on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 surgical extractions (D7210) provided on February 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have had extractions done previously and 
they were covered. You say that you assumed your supplemental benefit offered no limit on extractions. You 
also say that you feel you are paying double to the plan and the provider. The Plan denied your request. The 
Plan says surgical extractions are not listed as 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, the surgical extractions are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 surgical 
extractions (D7210) provided on February 3, 2022.