Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), respiratory virus, 12-25 targets (87633) provided March 25, 2022.  
You asked the Plan to pay for the laboratory services. You say that CPT 87633 has denied in error. Please see 
the attached chart notes to support the medical necessity of this service. The Plan denied your request. The Plan 
says procedure code 87633 has met the associated deny relationship criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 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 infectious agent detection by nucleic acid (DNA or RNA), respiratory virus, 12-25 targets (87633) 
provided March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve harvest of bone for use in autogenous grafting 
procedure tooth #'s 2 and 14 (D7295). 
 
 
You asked the Plan to pre-approve the harvest of bone for use in autogenous grafting procedure tooth #'s 2 and 
14 (D7295). You say that you need the dental services and cannot afford to pay more than $2,900.00 for the 
procedure. You say your dental benefits should cover the gums as well. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 
harvest of bone for use in autogenous grafting procedure tooth #'s 2 and 14 (D7295).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx test (81551) provided February 24, 2022 
 
You asked the Plan to pay for the laboratory service. You say that you are the sole source provider for the 
ConfirmMDx test. Therefore, this test cannot be performed at a contracted laboratory. The Plan denied your 
request. The Plan says this test is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 81551 is listed under the Group 3 codes which states Genetic 
testing procedures submitted under the following CPT codes are unlikely to impact therapeutic decision-
making in the clinical management of the patient and will be denied automatically as not medically necessary.  
Per LCA A56199. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx test 
(81551) provided February 24, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) per lower 
left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
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. The Plan rules say that they 
cover periodontal scaling and root planing per quadrant every three years. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 21, 2020. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) 
per lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that there are no specialists within a reasonable 
distance from whom you can receive this treatment and are in-network. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your 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 Plans coverage rules apply in this case. 
 
 
  We looked at the file and the Plan rules. The Plan rules say that you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 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 pre-approve periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220), resin-based composite - three surfaces, anterior tooth #'s 11, 23, 
24 (D2332), resin-based composite - four or more surfaces or involving incisal angle (anterior) tooth #'s 8, 9 
(D2335), resin-based composite - three surfaces, anterior tooth #'s 25, 26 (D2332) and resin-based composite - 
three surfaces, anterior tooth #'s 6, 7, 10 (D2332) provided on June 2, 2022. 
 
You asked the Plan to pay for the dental services. 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 limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image 
(D0220), resin-based composite - three surfaces, anterior tooth #'s 11, 23, 24 (D2332), resin-based composite - 
four or more surfaces or involving incisal angle (anterior) tooth #'s 8, 9 (D2335), resin-based composite - three 
surfaces, anterior tooth #'s 25, 26 (D2332) and resin-based composite - three surfaces, anterior tooth #'s 6, 7, 10 
(D2332) provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and radiographic image (D0220) 
provided on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that these dental procedures should be covered by 
the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the oral evaluation and radiographic images are 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 an oral 
evaluation (D0140) and radiographic image (D0220) provided on June 2, 2022.  
 Your complaint about your experience with customer service 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on April 28, 2022 by an 
out-of-network provider 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 an oral evaluation (D0140) provided on April 28, 2022 by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on July 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 80307 provided on April 27, 2022. 
 
You asked the Plan to pay for procedure code 80307. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that they have agreed to pay for 
code G0481; however, there is insufficient information in the record to determine how the enrollee came to the 
servicing provider or whether the services were necessary. 
 
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. Specifically, the Plan has not provided a clear and valid reason for why the 
definitive drug testing can be paid but the presumptive drug testing cannot be paid with the information at 
hand. Therefore, we decided that the Plan has to pay for procedure code 80307 provided on April 27, 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 the dental services on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on July 
12, 2022. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that you do not understand why this 
service is not covered, because it is a necessary procedure to prepare the area for the final crown. 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 
gingivectomy or gingivoplasty (D4212) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 19, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom sleep apnea appliance (D9947) and the office 
visit for observation (D9430) provided on June 18, 2022, and June 26, 2022. 
 
You asked the Plan to pay for the custom sleep apnea appliance (D9947) and the office visit for observation 
(D9430). You say that you need this apparatus, and you would like the dentist to be reimbursed. The Plan 
denied your request. The Plan says the 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 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 
custom sleep apnea appliance (D9947) and the office visit for observation (D9430) provided on June 18, 2022, 
and June 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewings-
four radiographic images (D0274), periapical-first radiographic image (D0220), and the re-cement or re-bond 
of a crown (D2920) provided on June 7, 2022. 
 
You asked the Plan to pay more for these dental services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your 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 Plans coverage rules apply in this case.  
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. Additionally, a 50% coinsurance applies to Class 2 Basic Dental services and Class 3 Major Dental 
services after a $100 yearly deductible has been met. 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 the 
comprehensive oral evaluation (D0150), bitewings-four radiographic images (D0274), periapical-first 
radiographic image (D0220), and the re-cement or re-bond of a crown (D2920) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture- cast metal framework with 
resin denture bases (including any conventional clasps, rests, and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you really need this lower partial denture 
procedure, because you lost the previous lower partial denture. 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. Mandibular partial denture- 
cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) (D5214) but 
is limited to one procedure every five plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested mandibular partial denture- cast metal framework with resin denture bases 
(including any conventional clasps, rests, and teeth) (D5214) was exhausted on date of service July 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture- cast metal 
framework with resin denture bases (including any conventional clasps, rests, and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on June 15, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance (D4910). You say that the cleaning should be paid 
and you could pay the difference of the charges. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 
periodontal maintenance (D4910) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2392) on tooth #19 
provided on June 23, 2022. 
 
You asked the Plan to pay more for the resin-based composite. You say that it says it is more expensive, but is 
really the less expensive procedure. You also say if you had not had the resin-based composite done, you might 
have a crown, which would be more expensive. The Plan denied your request. The Plan says benefits have been 
paid on the least costly method of treatment, and you will be responsible for the remaining balance. 
 
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 contract says white fillings on 
posterior teeth will be processed as a silver filling and you are responsible for up to the contracted fee. The 
contract also says you are responsible for a 50% coinsurance. The record shows that you received a resin-based 
composite (D2392) on tooth #19, which is a posterior tooth. The Plan applied an alternate benefit of an 
amalgam (D2150) on tooth #19, and you are responsible for the 50% coinsurance, plus the difference between 
the allowed amounts. Therefore, we decided that the Plan does not have to pay more for the resin-based 
composite (D2392) on tooth #19 provided on June 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92522 billed for dates of service April 13, 
2022, to April 27, 2022. 
 
You asked the Plan to pay for procedure code 92522. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92522 is 1. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 92522 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92522 billed for dates of service April 13, 2022, to April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedure was necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of January 28, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on February 
9, 2022.