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

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7230), and an 
unspecified preventative procedure (D1999), provided by an out-of-network provider on February 17, 2022. 
 
You asked the Plan to pay for the removal of an impacted tooth and an unspecified preventative procedure. 
You say that you had another rotting tooth that needed to be removed. The Plan denied your request. The Plan 
says the rendered services are not covered 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 
removal of an impacted tooth (D7230), and an unspecified preventative procedure (D1999), provided by an 
out-of-network provider on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for endodontic therapy (D3320) provided on 
January 12, 2022. 
 
You asked the Plan to reduce the cost share for endodontic therapy. You say that you understand you should be 
responsible for 50%. You also say the Plan should pay the correct amount and explain why it is not 50%. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 50% 
coinsurance for endodontic therapy. The contract also says if you see an out-of-network dentist you might be 
billed more, even for services listed as a $0 copayment. 
 
The record shows you received endodontic therapy from an out-of-network provider. The record also shows 
that you are responsible for the total billed amount minus the amount the Plan paid. You have been asked to 
pay a total of $1,114 ($1,310 total billed amount - $196 the amount the plan paid = $1,114). Endodontic 
therapy falls 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 reduce the cost share 
for endodontic therapy (D3320) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250), a complete 
radiographic imaging set (D0210), and a comprehensive oral evaluation (D0150), provided by a participating 
provider on February 15, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots, a complete radiographic imaging set, and a 
comprehensive oral evaluation. You say that you disagree with this denial. The Plan denied your request. The 
Plan says the services that were covered have been correctly denied. 
 
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 does not cover the 
removal of residual tooth roots. The Plan does cover one a complete radiographic imaging set every five years, 
and one comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on June 9, 
2020, and one complete radiographic imaging on June 2, 2020. D7250 is not a covered benefit. Based on this 
information, we decided that the Plan's rules for a complete radiographic imaging set and a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the removal of 
residual tooth roots (D7250), a complete radiographic imaging set (D0210), and a comprehensive oral 
evaluation (D0150), provided by a participating provider on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (dental code D0140) and an extraction 
(dental code D7140) for tooth #8 provided on March 4, 2022. 
 
You asked the Plan to pay for an oral evaluation and an extraction. You say that you would like to appeal the 
bill because you already paid it. The Plan denied your request. The Plan says these services are not covered by 
the Plan's dental benefits. Also, the Plan contacted the provider on May 3, 2022, and the provider confirmed the 
balance was unpaid. 
 
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 oral 
evaluation (dental code D0140) and an extraction (dental code D7140) for tooth #8 provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum pump for a lower limb prosthesis (L5781). 
 
You asked the Plan to pre-approve a vacuum pump. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says that rules for coverage have not been met because the 
requested item is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that the primary function of a vacuum pump is to 
suspend the prosthetic limb. Additionally, products coded L5781 provide residual limb volume management 
and moisture evacuation.  
 
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 vacuum pump. Our reviewer says that 
the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee developed wounds on the residual limb after using a replacement socket in 2021. The enrollee 
requires another socket due to this situation. The request includes the addition of a vacuum volume 
management system to allow for better fit and removal of residual moisture between the limb and socket wall. 
While a vacuum management system may not be superior to standard suspension systems, it can be used in the 
context of wounds where there continues to be movement in the socket or hyperemia or hyperhydrosis on the 
enrollee's residual limb. Therefore, the requested vacuum volume management system can be considered 
medically necessary. 
 
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 vacuum pump have been met. Therefore, we decided that the Plan has to pre-
approve a vacuum pump for a lower limb prosthesis (L5781).  
 
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 dental extractions. 
 
You asked the Plan to pre-approve the dental extractions. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall under your dental coverage. 
 
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 
dental extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (dental 
code D7953), deep sedation/general anesthesia (dental code D9222), and guided tissue regeneration (dental 
code D4266) for teeth #23, #24, #25, and #26. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation, deep sedation/general 
anesthesia, and guided tissue regeneration. You say that you have another appointment with the provider and 
would like to appeal for the denied services. The Plan denied your request. The Plan says the denial for these 
services were correct because they are 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 pre-approve bone 
replacement graft for ridge preservation (dental code D7953), deep sedation/general anesthesia (dental code 
D9222), and guided tissue regeneration (dental code D4266) for teeth #23, #24, #25, and #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation on February 1, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that you were sent by your 
dentist to the periodontist after being advised of the work they needed as your dentist did not feel comfortable 
doing the work that needed to be done. The Plan denied your request. The Plan says The service in question is 
not covered under the member's contract under any normal circumstances. 
 
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 
comprehensive periodontal evaluation on February 1, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for an ECG provided on January 6, 2022. We also decided 
that the Plan does not have to waive the cost share for ambulance services provided on November 11, 2021, 
and January 6, 2022.  
 
You asked the Plan to waive the cost share for an ECG and ambulance services. You say that you disagree with 
the charges for services provided on November 11, 2021, and January 6, 2022. The Plan says that you have 
been charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the cost share for an ECG provided on January 6, 2022.  
 
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 no charge for outpatient diagnostic tests, including ECGs. 
 
The Plan says you must pay $8.31 for an ECG. Based on the Plan contract, however, there is no charge for an 
ECG. According to the EOC, there is no in-network or out-of-network benefit restrictions. Therefore, we 
decided that the Plan has to waive the cost share for an ECG proved on January 6, 2022.  
 
We also decided that the Plan does not have to waive the cost share for ambulance services provided on 
November 11, 2021, and January 6, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). The Plan contract also says that the enrollee must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services provided on November 11, 2021, and 
January 6, 2022. Ambulance services fall within the Ambulance Services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for ambulance services provided on November 11, 2021, and January 6, 2022. 
 
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 Core Buildup on February 16, 2022. 
 
You asked the Plan to pay for Core Buildup. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says per the plan's 2022 Evidence of Coverage (EOC) for 
dental services, core build up is not covered services under your plan. Therefore, no adjustment is needed at 
this time. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for Core Buildup on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft replacement (D4263) and guided tissue 
regeneration (D4246). 
 
You asked the Plan to pre-approve graft replacement and tissue regeneration. You say that the dental services 
are medical necessary. The Plan denied your request. The Plan says that a bone graft replacement (D4263) and 
guided tissue regeneration (D4246) are not covered by the enrollee's 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 pre-approve a bone graft replacement (D4263) and guided 
tissue regeneration (D4246).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant. You say that 
your father has different problems with his health, and the dental procedure is something that he needs to eat 
properly. The Plan denied your request. The Plan says the authorization request was denied because the 
member's plan does not cover this procedure. 
 
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 the 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Dental cleanings on August 4, 2021 to August 9, 2021. 
 
You asked the Plan to pay for Dental cleanings. You say that you state the denied services should be covered 
under 2021 out-of-network benefits. The Plan denied your request. The Plan says the claim processed correctly per 
the enrollee's 2021 benefit plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for Dental cleanings on August 4, 
2021 to August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown-porcelain/ceramic substrate (dental code D2740) for tooth #3 
provided on December 1, 2021. 
 
You asked the Plan to pay for a crown-porcelain/ceramic substrate. You say that a new crown was required, 
and the dentist supplied sufficient and clear information in the original request. The Plan denied your request. 
The Plan says that the original denial for the procedure was because there was no extensive decay or 
destruction of the tooth where the tooth cannot be fixed with only a filling. Does not cover crown for cosmetic 
reasons or for closing gaps. Veneers are not covered. Implant crowns are not covered. Does not cover "3/4" 
crowns. 
 
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. The plan has not substantiated their denial, as they have not provided any medical 
records or the x-rays used for the Plan's original denial decision for Maximus to review. Therefore, we 
decided that the Plan has to pay for a crown-porcelain/ceramic substrate (dental code D2740) for tooth #3 
provided on December 1, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room service provided on September 15, 2021.
You asked the Plan to pay for the emergency room service. You say that the service is medically necessary. The Plan denied your request. The Plan says there is no evidence this service was done twice on the same date.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the emergency room service provided on September 15, 2021 have been met. Specifically, there is no indication this service was done twice on the same date. Therefore, we decided that the Plan does not have to pay for the emergency room service provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) and an extraction (D7210) provided 
from December 1, 2021, to December 13, 2021. 
 
You asked the Plan to pay for an evaluation and extraction. You say that you were not told that the doctor had 
opted out of Medicare. The Plan denied your request. The Plan says that this provider has opted out of 
Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. 
  
Although the individual provider has opted out of Medicare, the record shows the services were billed to the 
oral surgery organization; not the individual provider. The oral surgery organization has not opted out of 
Medicare. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) and an 
extraction (D7210) provided from December 1, 2021, to December 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing coded as 81206, 81235, 
81301, 81292 and 81321 provided September 28, 2021. 
 
You asked the Plan to pay for the pathology testing. You say that you are requesting reconsideration of the 
determination and coverage of the Tempus Gene Panel Test at the in-network benefit level. The Plan denied 
your request. The Plan says the records do not support the service billed. 
 
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 81206, 81235, 81301, 81292 and 81321 are not supported in the medical 
record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided 
that Medicare rules for coverage of the pathology testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the molecular pathology testing coded as 81206, 81235, 81301, 81292 and 81321 
provided September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assessment for hearing aid (V5010) provided on 
November 17, 2021. 
 
You asked the Plan to pay for code V5010. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
V5010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code V5010 is Assessment for hearing aid.  
We find that CPT code V5010 is not supported in the medical record. Specifically, the records do not document 
that an assessment for a hearing aid was performed. Based on this information, we decided that Medicare rules 
for coverage of code V5010 have not been met. Therefore, we decided that the Plan does not have to pay for 
the assessment for hearing aid (V5010) provided on November 17, 2021.