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

 
We decided that the Plan does not have to pay for the porcelain crown (D2740 x 2), core build up (D2950 x 2), 
limited oral evaluation (D0140), and periapical x-ray (D0220) provided on January 28, 2022, by an out of 
network dentist. 
 
You asked the Plan to pay for the dental services. You say that this decision was necessary to protect your 
health. You also say that this was the only dentist in town to do this type of work. The Plan denied your 
request. The Plan says dental services received out of network 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, dental services you received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740 x 2), core build up (D2950 x 2), limited oral evaluation (D0140), and 
periapical x-ray (D0220) provided on January 28, 2022, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), and bitewing x-rays (D0274) 
provided from December 7, 2021, to December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want all of your bills paid for. You also say 
that your plan is lying about x-ray frequency. The Plan denied your request. The Plan says the claims processed 
correctly. 
 
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, core build up is not among those 
covered under this benefit. Additionally, bitewing x-rays are covered once per calendar year. The record shows 
that the Plan paid for bitewing x-rays that you received on September 1, 2021. Therefore, we decided that the 
Plan does not have to pay for the core build up (D2950), and bitewing x-rays (D0274) provided from December 
7, 2021, to December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve a partial denture. You say that your current denture is cutting your gums and 
needs to be replaced. The Plan denied your request. The Plan says you previously received a partial denture for 
the upper jaw in February of 2019, which is less than five years ago. This denture is covered once every five 
plan 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 Plan covers one upper 
partial denture - cast metal framework with resin base (D5213) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that this 
denture is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for one endosteal implant (D6010 x1). We decided that the 
Plan does not have to pay for the additional endosteal implant (D6010 x1).  
 
You asked the Plan to pay for the two surgical placements of implant bodies: endosteal implants (D6010 x2) 
provided on February 10, 2022. You say that you would like to appeal these services. The Plan says that the 
documentation does not demonstrate the need for implant placement. The Plan also says that the most cost-
effective treatment for replacing your missing teeth must be approved, and a partial denture is the more cost-
effective treatment. 
 
We decided that the Plan has to hold you harmless for one endosteal implant (D6010 x1).  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for one endosteal implant (D6010 x1) by a contracted provider. The Plan's 2022 Evidence of 
Coverage (EOC) states that authorization for Comprehensive Dental Services, including surgical placement of 
an implant, is required and is the responsibility of your provider. You received these endosteal implants from 
an in-network provider, and there is no documentation showing the treating provider requested prior 
authorization. The EOC does not indicate any limitations on one covered implant. Under Medicare rules, this 
means one endosteal implant (D6010 x1) is considered approved by the Plan. Therefore, we decided that the 
Plan has to hold you harmless for one endosteal implant (D6010 x1).  
 
We also decided that the Plan does not have to pay for the additional endosteal implant (D6010 x1). 
 
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, surgical placement of an implant is 
limited to once per 60 months per quadrant. The record shows that you received endosteal implants for tooth #'s 
19 and 20 on February 10, 2022. Tooth #'s 19 and 20 are both in the lower left quadrant, one of these implants 
is covered, and your benefit has been exhausted for implants for the lower left quadrant. Therefore, we decided 
that the Plan does not have to pay for the additional endosteal implant (D6010 x1). 
 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 pre-approve crowns (D2740) and a core buildup (D2950). 
 
You asked the Plan to pre-approve crowns and a core buildup. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for dental 
services have not been met. 
 
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 crowns and 
crown preparations once per tooth every five plan years.  
 
We looked at the file and Medicare rules. In this case, the enrollee has received prior instances of the services 
at issue within the past five plan years. Based on this information, we decided that the Plan's rules for coverage 
of crowns and a core buildup have not been met. Therefore, we decided that the Plan does not have to pre-
approve crowns (D2740) and a core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on October 19, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that you do not agree with the denial of this 
service. The Plan denied your request. The Plan says the endosteal implant is intended to address a dental 
problem and is not related to any medical condition. The Plan also says that it is not incidental to or an integral 
part of a medical service. 
 
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, a dental implant to hold a complete 
denture is a covered service under the implant category. There is no documentation provided showing that this 
endosteal implant was rendered in order to hold a complete denture in place. Therefore, we decided that the 
Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) provided on 
October 19, 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. Medicare rules say that lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code.
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950) for tooth #2. 
 
You asked the Plan to pre-approve a crown and core buildup. You say that there is a food trap between tooth #2 
and #3 and this service is necessary. The Plan denied your request. The Plan says that the criteria for medical 
necessity of a crown are not met. Crowns are not for cosmetic reasons or closing gaps, and there is no 
documentation of fracture or decay on tooth #2. 
 
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 a crown and 
core buildup 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 a crown and core buildup. Our reviewer 
says that the documentation provided meets the criteria for coverage for a core buildup (D2950) and a crown 
restoration (D2740) for tooth #2. Our physician reviewer found that tooth #2 contains a large restoration with 
an open contact between #2 and #3 and recurrent caries. In order to achieve a good contact with the distal 
surface of tooth #3, a crown restoration on tooth #2 is medically reasonable. Removal of the defective 
restoration and recurrent caries would require a core buildup prior to a crown restoration to provide good 
stability and retention for a crown. 
 
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 a crown and core buildup have been met. Therefore, we decided that the Plan 
has to pre-approve a crown (D2740) and core buildup (D2950) for tooth #2.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add tooth to existing partial denture (D5650) provided 
December 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for two teeth added to existing partial denture provided OON. You say that you 
needed a dentist who was close, and you did not realize this dentist was OON. The Plan denied your request. 
The Plan says there's no coverage for when services are rendered OON. 
 
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 
you are responsible for 100% of the cost of services provided OON.  
 
We looked at file and Medicare rules. In this case, the provider who rendered the services is not part of the 
Plans dental network. Based on this information, we decided that the Plan's rules for coverage of two teeth 
added to existing partial denture provided OON have not been met. Therefore, we decided that the Plan does 
not have to pay for the add tooth to existing partial denture (D5650) provided December 20, 2021, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you need both dentures because 
you have the upper denture and need the bottom denture because it is difficult for you to swallow after your 
surgery. The Plan denied your request. The Plan says that the documentation does not show health gums and 
good bone support. 
 
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 a mandibular 
partial denture 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 a mandibular partial denture. Our 
reviewer says that the documentation meets the criteria for coverage of medically reasonable and necessary for 
a mandibular removable partial denture (D5214). Our physician reviewer found there are multiple missing and 
hopeless mandibular teeth creating difficulty with adequate masticatory function. Our reviewer also found that 
after removal of the hopeless teeth, there appears to be adequate abutment teeth to support and stabilize a 
removable partial denture to achieve adequate masticatory function. 
 
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 a mandibular partial denture have been met. Therefore, we decided that the Plan 
has to pre-approve a mandibular partial denture (D5214).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued treatment with an out-of-network provider to 
include 21 additional dialysis visits. 
 
You asked the Plan to pre-approve continued treatment with an out-of-network provider to include 21 
additional dialysis visits. You say that 21 additional visits for dialysis with the out-of-network provider is 
medically necessary. The Plan denied your request. The Plan says the enrollee can safely transition to an in-
network provider following the 24 approved visits with the out-of-network provider. The 21 additional visits 
are not necessary at this time. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued treatment with an out-of-
network provider to include 21 additional dialysis visits. Our reviewer says that the enrollee can safely 
transition to an in-network provider following the 24 approved visits with the out-of-network provider. The 21 
additional visits are not necessary at this time. Our physician reviewer found the record indicates that the 
enrollee requires hemodialysis. The record provided does not document that transferring the enrollee's care to a 
network provider would be medically inappropriate and/or contraindicated at this time. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued treatment with an out-of-network provider to include 21 additional 
dialysis visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued 
treatment with an out-of-network provider to include 21 additional dialysis visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care following the right knee 
joint replacement surgery (CPT code 27447). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27447 is not 
listed on the CMS Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory 
procedure and there is no documentation provided to support the expectation the enrollee will require a greater 
than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative 
complications, reconsideration for inpatient level of care can be performed on concurrent review with updated 
clinical information. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that inpatient hospital care is not necessary with this 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care following the right knee joint replacement 
surgery (CPT code 27447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft, first sight in quadrant 
(D4264) and bone replacement graft, each additional sight in quadrant (D4263). 
 
You asked the Plan to pre-approve the dental services. You say that grafting is highly recommended together 
with the Osseous surgery for much better results and longevity of the existing teeth. This is medically 
necessary. The Plan denied your request. The Plan says this service is not listed as covered under the Plan 
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 health Plan contract says 
that any dental services not listed in the table of covered services in the Plan's Dental Benefit Limitations and 
Exclusions Guide is not covered. 
 
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 the 
bone replacement graft, first sight in quadrant (D4264) and bone replacement graft, each additional sight in 
quadrant (D4263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 implant supported crowns (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental implant and all associated services are excluded from coverage. 
 
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 implant supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve 9 implant supported crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel testing provided on August 25, 2021, 
billed with codes 81206, 81235, and 81321. 
 
You asked the Plan to pay for the gene panel as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this single panel should have been billed with a single panel code. 
Therefore, the Plan has only approved 11 of the 14 billed line items. 
 
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 panel is NGS testing and was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the gene panel as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel testing 
provided on August 25, 2021, billed with codes 81206, 81235, and 81321.