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

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350) provided on December 13, 2021. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you were not aware, nor 
were you informed by the dentist, that this service would not be covered. You also say that you are on social 
security and cannot afford the payment. The Plan denied your request. The Plan says this service is not a 
covered benefit 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 two 
dimensional (2D) oral/facial photographic image (D0350) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for teeth #8, #9, and #15 to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a crown. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the requested dental services are not medically necessary. 
 
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 Plan covers a crown 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 pre-approve a crown. Our reviewer says that the 
requested crowns are not medically necessary. Our physician reviewer found given the lack of substantial 
missing or damaged tooth structure, and the periodontal involvement of #15, the requested crowns would not 
be considered necessary. 
 
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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for teeth #8, #9, and #15 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two porcelain fused to high noble metal retainer crowns 
(D6750). 
 
You asked the Plan to pre-approve the retainer crowns. You say that these crowns are necessary. The Plan 
denied your request. The Plan says this specific type of retainer crown is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plan does cover some retainer crowns; however, a porcelain fused 
to high noble metal retainer crown (identified as code D6750) is not among those listed as covered by your 
benefit. You may wish to work with your provider and the Plan to see if a retainer crown made of other 
materials may be covered and appropriate for your treatment. Therefore, we decided that the Plan does not have 
to pre-approve two porcelain fused to high noble metal retainer crowns (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that the patient lost her existing 
denture. You also say that a new cast metal denture is needed for the patient to properly chew food. The Plan 
denied your request. The Plan says this service exceeds the maximum count allowed per period. 
 
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, maxillary partial denture (D5213) is 
limited to one procedure every five plan years. The record shows that the enrollee received a maxillary partial 
denture (D5213) on June 3, 2020 and the enrollee's maxillary partial denture (D5213) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that a new crown was not inserted. You 
also say that if you had left it without repair it could have caused more damage with the open tooth. The Plan 
denied your request. The Plan says this service is not a covered benefit 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 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 re-
cement or re-bond crown (D2920) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on December 29, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that your dentist said the bone replacement 
graft was mandatory. You also say that the dentist would not pull your tooth unless you agreed to the graft. The 
Plan denied your request. The Plan says this service is not covered by the 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 pay for the bone 
replacement graft for ridge preservation (D7953) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750), two core buildups (D2950), a 
prefabricated post and core in addition to a crown (D2954), a pontic (D6240) and two retainer crowns (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a crown (D2750), two core buildups (D2950), a prefabricated post and core in addition to a crown (D2954), a pontic (D6240) and two retainer crowns (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the partial denture (D5225) provided 
on December 1, 2021. 
 
You asked the Plan to pay an additional amount for the dental item. You say that you were lacking $51.45 in 
your annual maximum. You say that had you been able to pay the $51.45 you would only have been liable for 
$559.82. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 partial dentures are listed as 
covered, the cost share amount applied is correct. The record shows that once this maximum benefit amount is 
reached, you are responsible for 100% of the cost of in & out of network dental services and dental providers may balance bill you if charges are above the allowed amount. The record also shows that the maximum benefit was reached in the processing of this claim. 
 
Date of Service Plan Paid 
2/18/2021 $244.07 
2/25/2021 $51.73 
4/26/2021 $162.92 
8/5/2021 $32.90 
12/1/2021 $508.38 
TOTAL: $1,000 
 
Therefore, we decided that the Plan does not have to pay an additional amount for the partial denture (D5225) 
provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when 
required (D2950), mandibular partial denture (D5226), surgical extraction (D7210), and bone replacement graft 
for ridge preservation (D7953) provided on October 5, 2021. 
 
You asked the Plan to pay for the crown, core buildup, mandibular partial denture, surgical extraction, and 
bone replacement graft. You say that you would like to appeal these services. The Plan denied your request. 
The Plan says these services are not covered benefits 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 crown 
(D2740), core buildup, including any pins when required (D2950), mandibular partial denture (D5226), 
surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9083) provided to the enrollee on July 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not valid for Medicare purposes. 
 
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 procedure code S9083 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (S9083) provided 
to the enrollee on July 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a nasal endoscopy procedure performed on 
May 14, 2021. 
 
You asked the Plan to waive the deductible for the nasal endoscopy. You say that you thought the procedure 
was covered and you would only have a $35 copayment. The Plan denied your request. The Plan says the 
correct amount was applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the nasal endoscopy was performed on May 14, 2021. Therefore, we decided that the Plan 
does not have to waive the deductible for a nasal endoscopy procedure performed on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 82570 and 82043 remain not supported. 
 
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 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 laboratory services provided to the enrollee on October 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 2, 2021 to October 
14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing reconsideration of payment for 
services provided to member. The Plan denied your request. The Plan says we have determined that these 
services are not urgent or emergent, nor were they approved in advance. 
 
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 psychotherapy provided on September 2, 2021 to 
October 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic continuous glucose monitor (CGM) coded K0554. 
 
You asked the Plan to pre-approve a CGM. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical necessity rules for coverage for the 
requested item have not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 a CGM. Our reviewer says that the 
requested item is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee is on multiple daily injection therapy and is prescribed a regimen where the enrollee adjusts the doses 
according to blood glucose level at meals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CGM have been met. Therefore, we decided that the Plan has to pre-approve a 
therapeutic continuous glucose monitor (CGM) coded K0554.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that service was provided to the enrollee, and 
you would like the claim paid. The Plan denied your request. The Plan says both the rendering and referring 
providers are both out-of-network providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 the laboratory services provided on November 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 31, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the provider should 
be an in-network provider since there is no one else near your residence. The Plan denied your request. The 
Plan says the copayment is the same if the provider of this service is in-network or an out-of-network provider. 
Therefore, the proper copayment was applied. 
 
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 a $290 
copayment for an in-network or an out-of-network ground ambulance transportation per date of service 
regardless of the number of trips.  
 
  You have been asked to pay a $290 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 waive the copayment for 
ambulance transportation provided on October 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on 
December 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment is not allowed for an assistant at surgery for CPT code 27062. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27062. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services provided to the enrollee on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded as 
81407, 81238, 81408, 81439, 81411 and 81479 provided December 21, 2020. 
 
You asked the Plan to pay for the screening testing. You say that please review the additional documentation 
provided and consider overturning the coverage decision regarding the respiratory test performed. The Plan 
denied your request. The Plan says this service is not covered by the Medicare. 
 
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 81407, 81238, 81408, 81439, 81411 and 81479 is not supported in the 
medical record. Specifically, the Plan made multiple outreach attempts to the providers office to verify if the 
doctor wrote the order for cardiovascular genetic testing. Routine screening and prophylactic testing for lipid 
disorder are not covered by Medicare. While lipid screening may be medically appropriate, Medicare by statute 
does not pay for it. Based on this information, we decided that Medicare rules for coverage of the screening 
testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment 
genetic screening testing coded as 81407, 81238, 81408, 81439, 81411 and 81479 provided December 21, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services received on June 7, 2021. 
 
You asked the Plan to pay for the services. You say that you received a final notice from the laboratory to pay 
this claim. The Plan denied your request. The Plan says that the provider needs to bill with a Medicare-
approved code for this service. 
 
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. 
 
You were referred for the services by a contract provider. The services were provided by a contract provider. 
The file does not show that the Plan provided notice that the services would not be covered. Under Medicare 
rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for laboratory services received on June 7, 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.