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

 
We decided that the Plan does not have to pre-approve an Endosteal implant to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an Endosteal implant. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says service is not covered under the 
member's benefit package. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an Endosteal implant to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on January 6, 2022. 
 
You asked the Plan to pay for the intraoral x-ray. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as you have already 
received them within the last 5 years. 
 
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 indicates that you 
received these services on March 10th, 2020, which is less than 5 years ago. 
 
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 
intraoral x-ray (D0210) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on December 6, 2021. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused. You say that the two dental 
emergencies you had involved two entirely different teeth and two different dates of service. The Plan denied 
your request. The Plan says the service exceeds the frequency limitation in benefit plan. The Plan also says that 
they reviewed the members claim history and verified that on November 16, 2021, the member received this 
service from a non-participating provider, with the Plan paying $46.00. 
 
 
 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 contract says that a  
limited exam to evaluate a problem is limited to one procedure per plan year. 
 
We looked at the file, the Plans rules, and Medicares rules, and since this service was received on November 
16, 2021, and paid for by the Plan, the services requested in this appeal exceed the frequency limitation in the 
benefit plan. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem 
focused (D0140) provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
March 12, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81206 and 81292) provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on July 30, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel plays an important role in establishing 
specific mutations. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this was not billed with one single code. Therefore, only 9 of the 11 codes 
will be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This is an NGS panel that was not billed with a single panel code as 
required.  Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 
7, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on June 16, 2021. 
 
You asked the Plan to pay for a consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician. You say that you were told the services would be covered, and is part of your 
benefits. The Plan denied your request. The Plan says according to the member's dental benefits, consultation 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration 
(D9610) and gingival irrigation-per quadrant (D4921) for teeth # 8,13, 18 and 30. 
 
You asked the Plan to pre-approve therapeutic parenteral drug, single administration and gingival irrigation-per 
quadrant. You say that you are on a fixed income and are unable to pay for the extractions and partials. The 
Plan denied your request. The Plan says the service is not covered under your 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 therapeutic parenteral drug, single 
administration (D9610) and gingival irrigation-per quadrant (D4921) for teeth # 8,13, 18 and 30 are not among 
those covered under this benefit. As a Plan member you can receive a 20% to 50% discount on dental services. 
Just see a participating Plan dentist. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic parenteral drug, single administration (D9610) and gingival irrigation-per quadrant (D4921) for 
teeth # 8,13, 18 and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical x-ray (D0220), 
and additional periapical x-rays (D0230) provided on March 7, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that these services should be covered because 
you needed to have them done. The Plan denied your request. The Plan says that a limited oral evaluation 
(D0140), periapical x-ray (D0220), and additional periapical x-rays (D0230) are not covered by your 
supplemental 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 a limited 
oral evaluation (D0140), periapical x-ray (D0220), and additional periapical x-rays (D0230) provided on March 
7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
January 20, 2022, and a limited re-evaluation (D0170) provided on January 26, 2022. 
 
You asked the Plan to pay for a pre-diagnostic test and re-evaluation. You say that you do not agree with the 
denial of dental services. The Plan denied your request. The Plan says that an adjunctive pre-diagnostic test 
(D0431) and a limited re-evaluation (D0170) are not covered by your dental 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 an 
adjunctive pre-diagnostic test (D0431) provided on January 20, 2022, and a limited re-evaluation (D0170) 
provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid genetic testing provided on April 20, 2021, billed 
with code 81445. 
 
You asked the Plan to pay for the thyroid genetic testing as billed. You say that this testing is the ThyraMIR 
and ThyGeNEXT panels which are covered to determine the risk of malignancy due to a thyroid nodule. The 
Plan denied your request. The Plan says 81445 is included in payment for 0018U. The use of modifier -59 is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that there are covered thyroid genetic tests, 
ThyraMIR and ThyGeNEXT, that are billed with codes 0018U and 0245U, respectively. 
 
We looked at the file and Medicare rules. The appeal letter and results indicate that both ThyraMIR and 
ThyGeNEXT testing was performed. However, the ThyGeNEXT test was not billed with the correct code 
based on the LCA. Based on this information, we decided that Medicare rules for coverage of the thyroid 
genetic testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
thyroid genetic testing provided on April 20, 2021, billed with code 81445.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
pulp vitality tests (D0460) provided February 21, 2022. 
 
You asked the Plan to pay for the limited oral exam and pulp vitality tests. You say that other evaluations are 
covered so you do not understand why this one is not. The Plan denied your request. The Plan says these 
services are 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 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 
limited oral evaluation - problem focused (D0140) and pulp vitality tests (D0460) provided February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown - porcelain/ceramic (D6740) and pontic - 
porcelain/ceramic (D6245) provided December 14, 2021. 
 
You asked the Plan to pay for the retainer crowns and pontic. You say that you are unable to find in your 2021 
Summary of Benefits that these services are excluded. The Plan denied your request. The Plan says they have 
provided a one-time exception to cover the retainer crowns. These have been paid up to the annual dental 
maximum. The pontic 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 Plan's coverage rules apply in this case. The Plan covers two crowns 
per calendar year. This benefit includes an annual maximum of $1,000. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the retainer crowns 
have been reprocessed as a covered benefit. At the time the claim for the retainer crowns were processed, you 
had $955 remaining in your annual dental maximum. This amount was applied to the retainer crowns. 
Therefore, we decided that the Plan does not have to provide additional payment for the retainer crowns 
(D6740 provided December 14, 2021. Though the Plan offers dental benefits in excess of Medicare coverage, 
pontics are not among those covered services.  Therefore, we decided that the Plan does not have to pay for the 
pontic - porcelain/ceramic (D6245) provided December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided July 21, 2021. 
 
You asked the Plan to pay for the complete upper denture. You say that you were told by a customer service 
representative that his provider was covered. The Plan denied your request. The Plan says this service is not 
covered because the provider has opted out of Medicare. 
 
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 the complete upper denture when you see any licensed dental provider who accepts Medicare patients in the United States 
and has not opted out of Original Medicare. 
 
We looked at the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the complete upper denture have not been met. Therefore, we 
decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided July 21, 2021.  
 
Your complaint about potentially receiving misinformation from a plan representative 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe inserts. 
 
You asked the Plan to pre-approve these services. You say that your gait is so bad that it would inhibit your leg 
from healing properly. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for motion fluoroscopic evaluation of swallowing function 
services (92611, 74240, 74230) provided on November 17, 2021. 
 
You asked the Plan to pay for fluoroscopic evaluation of swallowing function. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services are not payable because they 
were not provided in a Medicare-approved setting. 
 The Plan must follow Medicare rules. Medicare rules say that questions of patient safety have yet to be 
resolved for these types of services to be performed in a skilled nursing facility, nursing home, or home 
environment. As such, this procedure will be reimbursed only when medically necessary and performed in one 
of the specified settings. 
 
We looked at the file and Medicare rules. Although this claim was billed with a Place of Service (POS) code 
for an office setting (11), the records support that these services were performed in the enrollee's home by a 
mobile unit. Based on this information, we decided that Medicare rules for coverage of fluoroscopic evaluation 
of swallowing function have not been met. Therefore, we decided that the Plan does not have to pay for motion 
fluoroscopic evaluation of swallowing function services (92611, 74240, 74230) provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81292, and 81301) provided 
on October 20, 2021. 
 
You asked the Plan to pay for codes 81206, 81292, and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
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.  
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81292, and 81301) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pontic -Porcelain/Ceramic crown for tooth 19 (D6245) 
and white glass caps for tooth 18 and for tooth 20 (D6740). 
 
You asked the Plan to pre-approve a Pontic -Porcelain/Ceramic crown for tooth 19 and white glass caps for 
tooth 18 and for tooth 20. You say that your research indicates that restorative dentistry is the term dental 
professionals use to explain how they replace missing or damaged teeth. You also say that fillings, crowns, 
bridges and implants are common restorative options. The Plan denied your request. The Plan says these 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a Pontic -Porcelain/Ceramic crown for tooth 19 (D6245) and white glass caps for tooth 18 and for tooth 20 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited exam to evaluate a problem (dental code D0140) 
for tooth #1 through #32 provided on February 1, 2022. 
 
You asked the Plan to pay for a limited exam to evaluate a problem. You say that you thought the Plan covered 
the service. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because one limited exam to evaluate a problem is covered once per year and you previously received a limited 
exam to evaluate a problem on January 31, 2022. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers 1 limited 
exam to evaluate a problem per plan year. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received a limited exam to evaluate a 
problem on January 31, 2022; therefore, the benefit was exhausted for the date of service of February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited exam to evaluate a problem (dental code 
D0140) for tooth #1 through #32 provided on February 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Emergency department visit (99285) provided on July 9, 2021. 
 You asked the Plan to pay for code 99285. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 99285 
provided twice on July 9, 2021. 
 
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 department visit 
(99285) provided on July 9, 2021, have been met. In this case, there were no medical records provided 
confirming that two separate emergency department visits (99285) were provided on July 9, 2021, by this 
provider. The file shows that the Plan paid for one claim submitted with code 99285 by this provider. 
Therefore, we decided that the Plan does not have to pay for the Emergency department visit (99285) provided 
on July 9, 2021.