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

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration in 
conjunction with periradicular surgery (D3431). 
 
You asked the Plan to pre-approve the dental service. You say that you are experiencing pain. You also say that 
you need this service. The Plan denied your request. The Plan says biologic materials to aid in tissue 
regeneration in conjunction with periradicular surgery 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 biologic materials to aid 
in tissue regeneration in conjunction with periradicular surgery is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in tissue 
regeneration in conjunction with periradicular surgery (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), surgical extraction 
(D7210), and bone replacement graft for ridge preservation (D7953) provided on December 23, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration, surgical extraction, and bone replacement graft. 
You say that the Plan should cover these dental services as emergency outpatient surgery from an out-of-
network provider because this was an emergency dental visit as you needed an emergency tooth extraction due 
to your tooth being split into two pieces. The Plan denied your request. The Plan says for the date of service 
billed, basic/major dental services are not covered under your plan. The Plan also says that you only had 
preventive dental benefits. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266), surgical extraction (D7210), and bone replacement graft for ridge 
preservation (D7953) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper left and 
upper right quadrants, bone replacement graft (D4263) for tooth # 22, and implants (D6010) for teeth # 20, 22, 
24, 26, and 29. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay out of pocket for 
the deep gum and root cleaning. You say that you are on a fixed income. You also say that you would like your 
dental implants to be redone because the initial implants were done incorrectly. The Plan denied your request. 
The Plan says the requested services 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, the requested bone replacement graft 
and implants are not among those covered under this benefit. Additionally, the requested scaling and root 
planing for the upper left and upper right quadrants are not necessary. The record shows that you do not have 
upper teeth. Since you do not have upper teeth, there is no need for these services to be performed. Therefore, 
we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper left and 
upper right quadrants, bone replacement graft (D4263) for tooth # 22, and implants (D6010) for teeth # 20, 22, 
24, 26, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) and consultation 
(D9310) provided on October 13, 2021, and October 20, 2021. 
 
You asked the Plan to pay for the full mouth debridement and consultation. You say that you did not ask the 
provider to prepare you for a root canal or do a deep cleaning. You also say that you would like this bill to be 
cancelled. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. The Plan also says that you did contact the Plan prior to the date of service to verify benefits and 
provider eligibility. During the call you were sent a list of in-network provider as well as a copy of your plan 
benefits which shows which services are covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) and consultation (D9310) provided on October 13, 2021, and October 20, 2021.  
 
Your complaint about the issues you experienced with the treating provider 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81479) provided on 
April 16, 2021. 
 
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was billed correctly. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular 
screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary 
cardiovascular screening (81479) provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported cast metal crown (D6063) and 
an implant supported crown (D6066). 
 
You asked the Plan to pre-approve the abutment supported cast metal crown and implant supported crown. You 
say that the enrollee had an implant approved and provided. The Plan denied your request. The Plan says these 
services are not covered under the enrollee's benefit 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. 
 
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 an 
abutment supported cast metal crown (D6063) and an implant supported crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that your previous dentures were too big for you 
to eat with. You also say that you lost your dentures on the bus. The Plan denied your request. The Plan says 
dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached. 
 
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 and dentures are listed as covered once 
every 5 years, the frequency limit has been reached. The record shows that you received a partial upper and 
lower denture on January 27, 2021. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4), cone beam computed tomography (CT) capture and interpretation (D0367), oral hygiene 
instructions (D1330), bitewing x-rays (D0274), and comprehensive oral evaluation (D0150) 
 
You asked the Plan to pay for the 2D oral/facial photographic images, cone beam CT capture and 
interpretation, oral hygiene instructions, bitewing x-rays, and comprehensive oral evaluation. You say that you 
clarified with the provider that you only wanted to receive dental services that would be covered by your 
insurance. You also say that you cannot take responsibility for these charges because of your economic 
situation. The Plan denied your request. The Plan says the 2D oral/facial photographic images, cone beam CT 
capture and interpretation, and oral hygiene instructions are not covered expenses under your dental plan. The Plan also says that your bitewing x-rays and comprehensive oral evaluation benefits have been satisfied 
and the frequency limitations have 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, 2D oral/facial photographic image 
(D0350), cone beam CT capture and interpretation (D0367), and oral hygiene instructions (D1330) are not 
among those covered under this benefit. The contract says that bitewing x-rays are limited to one set per 
calendar year. The record shows that you received bitewing x-rays (D0274) on May 4, 2021 and your bitewing 
x-rays benefit has been exhausted. The Plan contract also says that comprehensive oral evaluation is limited to 
one procedure code every three years. The record shows that you received a comprehensive oral evaluation 
(D0150) on March 14, 2019 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images 
(D0350 x4), cone beam computed tomography (CT) capture and interpretation (D0367), oral hygiene 
instructions (D1330), bitewing x-rays (D0274), and comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy - premolar 
(D3347) and retreatment of previous root canal therapy - molar (D3348) provided June 4, 2021. 
 
You asked the Plan to pay for the retreatment of previous root canals. You say that you would like this service 
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 
retreatment of previous root canal therapy - premolar (D3347) and retreatment of previous root canal therapy - 
molar (D3348) provided June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine endosteal implants (D6010 x9). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you have difficulty eating due to 
missing teeth, and your current dentures cause pain and bleeding. The Plan denied your request. The Plan says 
this service is not covered under your benefit 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. 
 
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 nine 
endosteal implants (D6010 x9).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-positional patient support system, with 
integrated lift, patient accessible controls (E0636). 
 
You asked the Plan to pre-approve a patient support system lift. You say that you live alone in a two-level 
home. You also say that you are having hip replacement surgery and the stair chair lift is needed in order to 
access your primary living quarters. The Plan denied your request. The Plan says the requested supplier is out 
of network and not a Medicare approved billing durable medical equipment (DME) supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve a multi-positional patient support 
system, with integrated lift, patient accessible controls (E0636).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says that the requested continued SNF care does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee does have documented skilled 
nursing needs. The enrollee requires daily wound care to hard-to-reach and hard-to-see wounds. The enrollee 
does not have documented skilled therapy needs. Daily skilled services are required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that imaging requires six weeks of provider directed treatment to be completed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has chronic 
low back pain without any red flags. However, he has had a full six week trial of physical therapy without any 
relief. The x-rays show degenerative changes at L4-5 and L5-S1. The enrollee fulfills the criteria for the 
requested MRI of the lumbar spine. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.  
 
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 three precision attachments (D5862 x3). 
 
You asked the Plan to pre-approve the precision attachments. You say that these services are medically 
necessary for your dentures because you do not have any gums to use the dentures with. The Plan denied your 
request. The Plan says this service is not included on your benefit 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 pre-approve three 
precision attachments (D5862 x3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on January 11, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging.  Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation.  Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal to be performed by an endodontist. 
 
You asked the Plan to pre-approve a root canal. You say that you cannot afford to pay for this service. The Plan 
denied your request. The Plan says there is no listed benefit for a root canal to be performed by an endodontist. 
 
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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a root canal to be performed by an endodontist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260) for all 4 quadrants, and bone 
replacement grafts (D4263) for teeth # 3, 19, and 30. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says osseous surgery and bone replacement grafts are limited to once per quadrant every 
3 years. The Plan also says that the frequency limits have 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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for osseous surgery for the upper 
right and lower right quadrants, and bone replacement grafts for teeth # 4 and 30 that you received on March 
18, 2021. Teeth # 3 and 4 are in the same quadrant, thus exhausting the benefit. Additionally, the record shows 
that the Plan paid for osseous surgery for the upper left and lower left quadrants, and bone replacement grafts 
for tooth # 19 that you received on May 26, 2021. Therefore, we decided that the Plan does not have to pre-
approve osseous surgery (D4260) for all 4 quadrants, and bone replacement grafts (D4263) for teeth # 3, 19, and 30.