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

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 27, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you had x-rays taken once in 2020, and once in 
2021. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded. 
 
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, bitewing x-rays (D0274) are limited to 
one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on April 20, 2021 
and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the bitewing x-rays (D0274) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic 
image (D0220), the core buildup, including any pins when required (D2950), the porcelain/ceramic crown 
(D2740), the limited oral evaluation (D0140), the endodontic therapy, of a premolar tooth (excluding final 
restoration) (D3320), and the endodontic therapy, of an anterior tooth (excluding final restoration) (D3310) 
provided from May 10, 2021, through June 7, 2021. 
 
You asked the Plan to issue reimbursement 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 the services 
provided in this case are not covered under your contractual policy as they were rendered by out of network 
dental providers. 
 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. Services obtained from dental 
vendors outside the network are not covered by the Plan.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plan contract states that you must obtain 
supplemental dental benefits from a provider in the Plans dental vendor network. Services obtained from 
vendors outside the network are not covered by the Plan. The services in this case were rendered by out of 
network dental vendors. Therefore, we decided that the Plan does not have to issue reimbursement for the 
intraoral-periapical first radiographic image (D0220), the core buildup, including any pins when required 
(D2950), the porcelain/ceramic crown (D2740), the limited oral evaluation (D0140), the endodontic therapy, of 
a premolar tooth (excluding final restoration) (D3320), and the endodontic therapy, of an anterior tooth 
(excluding final restoration) (D3310) provided from May 10, 2021, through June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
March 1, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like this service 
to be covered. The Plan denied your request. The Plan says your benefits for this service have been satisfied 
and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on March 1, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the additional intraoral periapical x-ray (D0230) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2021, billed with 
codes 81404 x2 and 81479 x2. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this is noncovered screening testing so only most of the claim was 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who wishes to use the results in the management of a specific medical problem.  
 We looked at the file and Medicare rules. The documentation does not show that the results will be used in the 
management of the enrollee's cardiovascular issues. The progress note makes no indication that this testing was 
planned. Based on this information, we decided that Medicare rules for coverage of the genetic testing as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 20, 2021, billed with codes 81404 x2 and 81479 x2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an 
extraction (D7210) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation, and an extraction to be performed by an 
oral surgeon. You say that the requested services are medically necessary The Plan denied your request. The 
Plan says the services at issue are not covered unless they are performed by a participating general dentist. 
Dental services performed by an oral surgeon 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 Plans coverage rules apply in this case. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, and an extraction to be performed by an oral surgeon have not 
been met. Specifically, the services at issue are not covered unless they are performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150), and an extraction (D7210) to be performed by an oral surgeon.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has pay the in network rate for the esophagogastroduodenoscopy, without biopsy 
(43245), and esophagogastroduodenoscopy, with biopsy (43239) provided on January 21, 2022. 
 
You asked the Plan pay the in network rate for the ambulatory surgical services. You say that the provider in 
this case is in network. The Plan denied your request. The Plan says that the correct out of network cost share 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $250 copayment for Outpatient hospital services - 
ambulatory surgical services.  
 
The Plan says you must pay 50% of the total cost for the ambulatory surgical services. Based on the Plan 
contract, however, you cannot be asked to pay more than a $250 copayment for the ambulatory surgical 
services. The provider in this case is listed as in network on the Plans website. Therefore, we decided that the 
Plan has pay the in network rate for the esophagogastroduodenoscopy, without biopsy (43245), and 
esophagogastroduodenoscopy, with biopsy (43239) provided on January 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that this is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for 
treatment of the enrollees health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested bone marrow aspirate is experimental. More research is 
needed to show safety and efficacy when used as bone graft material in spinal surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography coded 70450 and the service(s) 
provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on February 1, 2022. 
 
You asked the Plan to pay for the computed tomography and the service(s) provided between 10:00 PM and 
8:00 AM at 24-hour facility. 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 70450 and 99053 are not supported in the medical record. Specifically, these services 
were billed with a place of service of 22 (outpatient). The documentation shows that the enrollee was inpatient 
for this date of service. This means this service was billed with an incorrect place of service. Payment for code 
99053 cannot be made as payment for this service is bundled into other services which were denied. Based on this information, we decided that Medicare rules for coverage of the computed tomography and the service(s) 
provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we decided that the 
Plan does not have to pay for the computed tomography coded 70450 and the service(s) provided between 
10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0230 and D0350) provided on 
December 7, 2021. 
 
You asked the Plan to pay for dental codes D0230 and D0350. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says dental code D0350 is not covered under 
the Plan's supplemental dental benefit. Intraoral x-rays are limited to one procedure code per calendar year. The 
Plan paid for one intraoral x-ray (D0220) on December 7, 2021. Therefore, code D0230 is not covered as you 
met your benefit limit for this type of 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, dental code D0350 is not among those 
covered under this benefit. The Plan contract says Intraoral x-rays are limited to one procedure code per 
calendar year.  
 The Plan paid for one intraoral x-ray (D0220) on December 7, 2021. Therefore, code D0230 is not covered as 
you met your benefit limit for this type of service. Therefore, we decided that the Plan does not have to pay for 
the dental services (D0230 and D0350) provided on December 7, 2021.  
 
Your complaint about the providers office being rude and charging more than you believe you owe 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 pre-approve a tooth extraction. 
 
You asked the Plan to pre-approve a tooth extraction. You say that the service is medically necessary. The Plan 
denied your request. The Plan says dental services performed by an oral surgeon 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 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. Specifically, the requested service is through a oral surgeon and not a 
general dentist. This means the service is not covered. Therefore, we decided that the Plan does not have to pre-
approve a tooth extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services as in-network provided on
January 12, 2022.
You asked the Plan to pay for physician's services as in-network. The Plan denied your request. The Plan says
the services were not an urgent/emergent office visit.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services as in-network provided on January 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home covid-19 test, provided on January 18, 2022. 
 
You asked the Plan to pay for the at home covid-19 test. You say that the items should be covered. The Plan 
denied your request. The Plan says The coverage of COVID-19 home tests required for individual and group 
health plans under Section 6001 of the Family First and Coronavirus Recovery Act (FFCRA) does not apply to 
Medicare Advantage plans, and therefore, coverage is not provided through the reimbursement mechanism. 
Although this requirement does not apply to this type of plan, Triple-S Advantage, Inc. members can use their 
benefit of over-the-counter (OTC) products provided through the medical plan card to purchase COVID home 
tests. -19, either at our network pharmacies or through the Triple-S service at home. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at home covid-19 test have not been met. Specifically, you did not use the Plan's over-the-
counter benefit for these items and paid for the items out of pocket. This item is not covered by Medicare, and 
therefore, cannot be reimbursed. Therefore, we decided that the Plan does not have to pay for the at home 
covid-19 test, provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain crown (D2740) for teeth # 3 and 15, core build 
up (D2950) for teeth # 3 and 14, and white filling (D2394) for tooth # 2 provided from December 27, 2021, to 
January 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like this to be covered. You say that 
you were advised metal fillings were covered and ceramic fillings were not. You also say that your dentist 
advised they do not do metal fillings. The Plan denied your request. The Plan says crowns are core build up are 
not listed as covered services.
 
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 crowns and core build up are not 
among those covered under this benefit. Additionally, the record shows that white fillings for back teeth, 
including tooth # are paid at the rate of a silver filling. The record also shows that you are responsible for the 
50% coinsurance ($98.50) + the difference between the allowed amounts ($85). Therefore, we decided that the 
Plan does not have to pay for the porcelain crown (D2740) for teeth # 3 and 15, core build up (D2950) for teeth 
# 3 and 14, and white filling (D2394) for tooth # 2 provided from December 27, 2021, to January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81230, 81240, 81241, 81249, 81291, 
81408, and 81335) provided on May 11, 2021. 
 
You asked the Plan to pay for codes 81230, 81240, 81241, 81249, 81291, 81408, and 81335. 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 (81230, 81240, 81241, 81249, 81291, 81408, and 81335) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
procedure. The Plan denied your request. The Plan says the procedure is considered experimental at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Food and Drug Administration (FDA) contraindications for the Superion spacer 
include spinal instability, scoliosis, obesity, and osteoporosis (which have not been adequately addressed in the 
medical records.) There is no discussion of spinal instability on flexion/extension films. There is no 
documentation of the enrollees height, weight, or body mass index. There is no discussion of scoliosis of the 
lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a bone density 
scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the request for Vertiflex Superion interspinous device is not medically reasonable or 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 24, 2021, to 
August 13, 2021. 
 
You asked the Plan to pay for the home health care. You say that your colleague was advised that you did not 
need to bill out the RAP within 5 days. The Plan denied your request. The Plan says there was no exception 
request was submitted to waive the 5-day requirement for filing the RAP claim due to a circumstance beyond 
the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, July 24, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 24, 2021, to August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on January 5, 2021, and July 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you paid for these services with your personal 
Visa card and want to be reimbursed. The Plan denied your request. The Plan says routine dental care is not 
covered under your Plan.  You did not purchase the optional supplemental benefit which provides coverage of 
preventive dental care. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services you received on 
January 5, 2021, and July 13, 2021.