Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the manual therapy techniques 
(97140) provided from December 10, 2021, through December 20, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the manual therapy techniques (97140) 
provided from December 10, 2021, through December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cementing of a partial denture (D6930) provided on 
November 19, 2021. 
 
You asked the Plan to pay for re-cementing dentures. You say that your bridge fell out and you needed have it 
cemented back in. The Plan denied your request. The Plan says the re-cementing of a partial denture (D6930) is 
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 the re-
cementing of a partial denture (D6930) provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based one (D2391), two surface (D2331) fillings, and 
two surface amalgam fillings (D2150) provided on February 17, 2022. 
 
You asked the Plan to pay for the resin-based one, two surface fillings, and two surface amalgam fillings. 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 you have exceeded your benefit maximum for the calendar year. 
 
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 have 
exceeded your frequency limitations. Therefore, we decided that the Plan does not have to pay for resin-based 
one (D2391), two surface (D2331) fillings, and two surface amalgam fillings (D2150) provided on February 
17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on February 16, 2022, and osseous surgery (D4260) and osseous tissue regeneration aids (D4265) provided on 
March 2, 2022. 
 
You asked the Plan to pay for an evaluation, osseous surgery, and regeneration aids. You say that you feel the 
services were coded incorrectly and should have been covered. The Plan denied your request. The Plan says a 
comprehensive periodontal evaluation (D0180), osseous surgery (D4260), and osseous tissue regeneration aids 
(D4265) 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 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 
comprehensive periodontal evaluation (D0180) provided on February 16, 2022, and osseous surgery (D4260) 
and osseous tissue regeneration aids (D4265) provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services for a patient of extreme age (99100) 
provided on December 16, 2021. 
 You asked the Plan to pay for anesthesia services for a patient of extreme age. You say that the claim needs to 
be reprocessed for payment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of anesthesia services for a patient of extreme age have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia services for a patient of extreme age (99100) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on February 28, 2022. 
 
You asked the Plan to pay for limited oral evaluation - problem focused. You say that this service was provided 
by a dentist in the Plan, and it was an evaluation of a very painful fractured tooth, which, according to the 
dentist, will need to be removed. The Plan denied your request. The Plan says this is not covered under Plan 
benefits - D0140 - limited oral evaluation - problem focused. 
 
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 limited 
oral evaluation - problem focused (D0140) provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel coded as 81206, 81210, 81235, 
81272, 81275, 81276, 81292 and 81321 provided July 12, 2021. 
 You asked the Plan to pay for the laboratory services. You say that the Tempus Gene Panel was ordered by an 
in-network provider. The Plan denied your request. The Plan says service not covered under the Plan benefits. 
 
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 looked at the file, and Medicare rules. 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 laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel coded as 81206, 81210, 
81235, 81272, 81275, 81276, 81292 and 81321 provided July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
17, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says no separate payment is made for this code. 
 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 CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed for date of service December 17, 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), 
intraoral-periapical - first film (D0220) and retreatment of previous root canal therapy - prem (D3347) provided 
on February 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused, intraoral-periapical - first film and 
retreatment of previous root canal therapy - prem. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says while you are a member of the Plan, you must use network providers 
to get your medical care and services. 
 
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 a limited oral evaluation - problem focused 
(D0140), intraoral-periapical - first film (D0220) and retreatment of previous root canal therapy - prem 
(D3347) provided on February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction and residual root removal provided on 
April 4, 2022. 
 
You asked the Plan to pay for the dental extraction and residual root removal. You say that you feel that this 
should be covered. The Plan denied your request. The Plan says your dental care is covered under your 
Medicaid benefit through a third party. The provider was informed to submit a claim to this third party to 
receive Medicaid reimbursement. 
 
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 the dental extraction and residual 
root removal provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on December 27, 2021. 
 
You asked the Plan to pay for x-rays. You say that you were unaware you would have to pay out-of-pocket for 
the x-rays taken. The Plan denied your request. The Plan says this service is covered by the Plan's dental 
benefits; however, your benefit for one procedure per calendar year has been exhausted. 
 
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 one procedure 
in the intraoral x-ray group per calendar year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for one 
periapical x-ray provided on September 1, 2021; therefore, the benefit for periapical x-rays has been exhausted. 
Therefore, we decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on 
December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve guided tissue regeneration (D4266) around tooth #15. 
 
You asked the Plan to pre-approve tissue regeneration. You say that the service requested is medically 
necessary. The Plan denied your request. The Plan says that this service is not covered when you have gum 
surgery where teeth are missing. 
 
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 tissue 
regeneration 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 tissue regeneration. Our reviewer says 
that the criteria for coverage has been met. Our physician reviewer found guided tissue regeneration involves 
the placement of a resorbable barrier to prevent migration of soft tissue into an area where bone is needed to 
reform. In this case the treatment is medically reasonable and necessary for bone growth around tooth #15. 
 
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 tissue regeneration have been met. Therefore, we decided that the Plan has to 
pre-approve guided tissue regeneration (D4266) around tooth #15.  
 
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 a limited oral evaluation (D0140) provided on February 21, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says this service is covered by the Plan's dental benefits; however, your 
benefit for one procedure every plan year has been exhausted. 
 
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 one limited 
oral evaluation (D0140) per plan year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on January 19, 2022; therefore, the benefit for a limited oral evaluation has been 
exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on February 9, 2022. 
 
You asked the Plan to pay for dentures. You say that you contacted the Plan prior to services and were told the 
dentures would be covered and would pay $1,007 towards them. The Plan denied your request. The Plan says a 
maxillary partial denture (D5213) is 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 
maxillary partial denture (D5213) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, S8301, 99072, A4556, 
A4557, and A4649 provided on September 2, 2021. 
 
You asked the Plan to pay for codes A9279, S1015, S8301, 99072, A4556, A4557, and A4649. 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 CPT codes A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee Schedule. 
This means that CPT codes A9279, S1015, and S8301 are not valid for Medicare purposes.  
 
We also find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
CPT code 99072 is not separately payable.  
 
We also find that CPT codes A4556, A4557, and A4649 have a status indicator of P on the Physician Fee 
Schedule. This means that CPT codes A4556, A4557, and A4649 are not separately payable.  
 
Based on this information, we decided that Medicare rules for coverage of codes A9279, S1015, S8301, 99072, 
A4556, A4557, and A4649 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes A9279, S1015, S8301, 99072, A4556, A4557, and A4649 provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided February 3, 2021 
to March 3, 2021. 
 
You asked the Plan to pay for the chiropractic service. You say that you believe that these claims were denied 
in error and need to be reviewed and paid. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (G0283) provided February 3, 2021 to March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite fillings on January 24, 2022. 
 
You asked the Plan to pay for resin-based composite fillings. You say that you can't afford the service and that 
you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the provider is 
out-of-network and it was determined these services can be received in-network. 
 
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 if they are provided by an out-of-network provider. Therefore, we 
decided that the Plan does not have to pay for resin-based composite fillings on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging on February 1, 2022. 
 
You asked the Plan to pay for panoramic imaging. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says panoramic imaging is not a covered service 
according to the member's EOC. 
 
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 
panoramic imaging on February 1, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology therapy with an injection, fosaprepitant (J1453). 
 
You asked the Plan to pre-approve oncology therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says that the requested therapy does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve oncology therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found palonsetron and fosaprepitant are FDA approved for use for moderate to highly emetogenic 
chemotherapy. The enrollee will be receiving highly emetogenic chemotherapy, especially cisplatin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oncology therapy have been met. Therefore, we decided that the Plan has to pre-
approve oncology therapy with an injection, fosaprepitant (J1453).  
 
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 resin-based composite - two surfaces (D2392) and resin-
based composite - three surfaces (D2393) provided on January 24, 2022. 
 
You asked the Plan to pay for resin-based composite - two surfaces and resin-based composite - three surfaces. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says services 
provided by an out-of-network or non-contracted provider are not provided under this 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, you must use a participating network 
provider. Therefore, we decided that the Plan does not have to pay for resin-based composite - two surfaces 
(D2392) and resin-based composite - three surfaces (D2393) provided on January 24, 2022.