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

 
We decided that the Plan does not have to pay for the crown re-cement (D2920) provided on March 14, 2022. 
 
You asked the Plan to pay for the crown re-cement (D2920). You say that you would like this service covered. 
The Plan denied your request. The Plan says code D2920 is only covered if you purchase the platinum dental 
rider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
re-cement (D2920) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says there is not a medical need to control these 
power options through the joystick. The Plan also says that the enrollee is able to manage PWC controls 
independently. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must 
primarily serve a medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313) and an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0272), a periodic oral evaluation (D0120), 
and prophylaxis (D1110) provided on March 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you needed authorization to 
see an out-of-network provider. 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 without prior 
authorization. 
 
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 without prior authorizaiton. Therefore, we decided 
that the Plan does not have to pay for bitewing x-rays (D0272), a periodic oral evaluation (D0120), and 
prophylaxis (D1110) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921) and 
unspecified periodontal procedure, by report (D4999) provided March 24, 2022. 
 
You asked the Plan to pay for the gingival and unspecified periodontal procedure. You say that you thought 
there wouldn't be any charges for the services. The Plan denied your request. The Plan says these services are 
not covered under your 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 
gingival irrigation  per quadrant (D4921) and unspecified periodontal procedure, by report (D4999) provided 
March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - one 
surface, posterior (D2391) provided March 10, 2022. 
 
You asked the Plan to provide additional payment for the filling. You say that your partials never fit properly. 
The Plan denied your request. The Plan says you have exhausted your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services up to a $2,000 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $2,000 
allowance was applied to your claims on this date of service. You have been asked to pay the amount above the 
$2,000 maximum. This means you have been asked to pay the correct amount based on your contract with the 
Plan. Therefore, we decided that the Plan does not have to provide additional payment for the resin-based 
composite - one surface, posterior (D2391) provided March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic screening testing coded 81439, 81296, 81238, 
81410, 81411, and 81479 provided on February 8, 2021. 
 
You asked the Plan to pay for the genetic screening testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic screening testing at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the genetic screening testing coded 81439, 81296, 81238, 81410, 81411, and 81479 provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on 
October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 81206 and 81292 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural code, so one code should be billed for the entire 
panel. Review of the file does not support that only one code was billed for the panel provided. 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 laboratory services coded 81206 and 81292 
provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, x-rays and therapeutic activities provided by 
a chiropractor from January 13, 2022, to February 4, 2022. 
 
You asked the Plan to pay for the office visit, x-rays, and therapeutic activities. You say that you thought you 
only had a $20 copay per visit. The Plan denied your request. The Plan says all services other than manual 
manipulation of the spine are excluded when ordered or performed by a chiropractor. 
 
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 office visit, x-rays and therapeutic activities provided by a chiropractor 
from January 13, 2022, to February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D4342, D4999) received on February 9, 
2022 and February 10, 2022. 
 
You asked the Plan to pay for the services. You say that this dentist was a life-saver. The Plan denied your 
request. The Plan says the claim was processed appropriately.  
The plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms 
all cost sharing information (such as copayments, deductibles and coinsurance). Additionally, 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 various instances of D4342 were processed at a 50% coinsurance for a charge of $75.50 each. You are 
responsible for paying for D4999 as it not covered by the plan's supplemental benefit. Based on this 
information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services (D4342, D4999) received on February 9, 2022 
and February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided March 9, 2022. 
 
You asked the Plan to pay for the complete upper denture. You say that your dentures do not fit properly due to 
radiation treatments. The Plan denied your request. The Plan says this service 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. 
 
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 
complete denture - maxillary (D5110) provided March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an observational office visit (D9430), a comprehensive oral 
evaluation (D0150), and an intraoral complete series (D0210) provided on February 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of 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 an observational office visit (D9430), a comprehensive oral evaluation (D0150), and an intraoral 
complete series (D0210) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81206 and 81292 provided on 
September 13, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 81206 and 81292 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was billed for the panel provided. 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 coded 81206 and 81292 provided on 
September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), resin-based composite - one 
surface, anterior (D2330), periodic oral evaluation - established patient (D0120), and resin-based composite - 
two surfaces, posterior (D2392) provided March 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the website did not show that this provider was 
no longer in-network. 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 Plan's 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 prophylaxis - adult (D1110), resin-based composite - one surface, anterior (D2330), periodic oral 
evaluation - established patient (D0120), and resin-based composite - two surfaces, posterior (D2392) provided 
March 15, 2022, by an out-of-network (OON) provider.  
 
Your complaint about the Plan's website potentially providing incorrect or out-of-date information 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from November 20, 2021, through December 11, 2021. 
 
You asked the Plan to pay for the continued SNF care. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the continued inpatient skilled nursing 
facility care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 pay for the continued SNF care. Our reviewer says 
that the continued inpatient skilled nursing facility care provided was not medically necessary. Our physician 
reviewer found that the enrollee has a medical history of a right hip fracture requiring open reduction and 
internal fixation. He was admitted to a skilled nursing facility on October 25, 2021. Prior to the admission to 
the skilled nursing facility, the enrollee was independent with activities of daily living and mobility. The 
enrollee was discharged from therapy on November 19, 2021. He was considered modified independent to 
independent with all of his activities of daily living. A clinical progress note indicated that the enrollee was 
discharged from the skilled nursing facility with home healthcare services. Therefore, the enrollee no longer 
required skilled nursing and/or skilled rehabilitation services on a daily basis. The services rendered were not 
reasonable and necessary for the treatment of the enrollees illness or injury. Therefore, the continued skilled 
nursing facility care provided from November 20, 2021, through December 11, 2021 was not 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued inpatient skilled nursing facility (SNF) care provided from  
November 20, 2021, through December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on February 21, 2022. 
 
You asked the Plan to pay for an evaluation. You say that the dentist did not check your tooth history. The Plan 
denied your request. The Plan says that your benefit limit for the requested service has been exhausted. 
 
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 did not provide the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to determine if the benefit limit for a comprehensive oral evaluation has been 
exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150) 
provided on February 21, 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 a resin-based composite (code D2330) provided on 
February 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should not be responsible for the providers 
error. 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 a resin-based composite (code D2330) provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fractured his hip on July 8, 2022. You 
also say that the enrollee is being left in bed all day. The Plan denied your request. The Plan says based on 
Medicare guidelines, the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #18 (D2950) and crowns on tooth 
# 18, 20, 21, 28, and 29 (D2751). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says core build up (D2950) and crowns (D2751) 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 pre-approve core 
build up on tooth #18 (D2950) and crowns on tooth # 18, 20, 21, 28, and 29 (D2751).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), therapeutic procedures (97110), and 
electrical stimulation (G0283) provided from February 7, 2022, through February 28, 2022, rendered by a 
chiropractor. 
 
You asked the Plan to pay for the services rendered by a chiropractor. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says the only services covered by a 
chiropractor is the manual manipulation of the spine to correct a subluxation. 
 
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 manipulations of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), therapeutic procedures (97110), and electrical 
stimulation (G0283) provided from February 7, 2022, through February 28, 2022, rendered by a chiropractor.