Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2021 billed with 
codes 81210, 81235, and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The 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 was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 24, 2021 billed with codes 81210, 81235, and 81275.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330 and D2392) provided by a 
participating provider on July 29, 2022. 
 
You asked the Plan to pay for resin-based composites. You say that you are on a fixed income, and you cannot 
afford this. The Plan denied your request. The Plan says the enrollee only has preventative dental service 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composites (D2330 and D2392) provided by a participating provider on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panoramic x-ray (D0330). 
 
You asked the Plan to pre-approve a panoramic x-ray. You say that you only had one x-ray in October of last 
year. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 14, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a panoramic x-ray (D0330).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation (HNS) implant (64582,
L8680, L8688, C1778, C1767, C1787).

You asked the Plan to pre-approve the surgical procedure. You say that the requested procedure is medically
necessary for your life-threatening condition. The Plan denied your request. The Plan says the Medicare
coverage criteria has not been met.

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 surgical procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found based on available clinical documentation, the request for HNS implantation does not
meet criteria for health plan coverage. Among the criteria for health plan coverage of HNS implantation is the
requirement that PSG be performed within 24 months of the first HNS implant consultation. In this case, the
initial consultation was November 9, 2021 and the last PSG was performed May 31, 2018. While clinical
documentation from May 2, 2022 indicated that a new PSG was recommended, the results of that study were
not available. Overall, the available clinical documentation did not show evidence of PSG being performed
within 24 months of HNS implant consultation. In summary, the requested services for HNS implantation are
not medically reasonable and 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 surgical procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve hypoglossal nerve stimulation (HNS) implant (64582, L8680, L8688, C1778,
C1767, C1787).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 28, 2022, and a partial mandibular denture (D5214) provided on March 24, 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 your benefit for the requested items or services has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for a comprehensive oral evaluation was exhausted on date of service September 18, 2020. 
The record also shows your benefit for a partial mandibular denture was exhausted on date of service 
November 6, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) provided on February 28, 2022, and a partial mandibular denture (D5214) provided on 
March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you did not like the service 
provided by the in-network provider. The Plan denied your request. The Plan says dental services from an 
OON provider 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. 
 
 
 
 
 
 
 
 You are requesting dental services from an OON 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 
OON provider. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 22, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) provided by on 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) and prophylaxis 
(D1110) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you suffer from a disability and feel 
comfortable with this OON dentist you are requesting to see. The Plan denied your request. The Plan says 
dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a periodic 
oral evaluation (D0120) and prophylaxis (D1110) to be rendered 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 comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on March 9, 2021, by an out-of-network (OON) provider 
 
You asked the Plan to pay for the dental services. You say that you do not believe the enrollee was seen on this 
date of service. 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. The Plan also says that during your call 
with the Plan prior to this date of service, you did not verify the treating provider's status. 
 
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 the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided 
on March 9, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #6 and a core buildup, 
including any pins when required (D2950) for tooth #6. 
 
You asked the Plan to pre-approve the crown and core buildup. You say that these services are medically 
necessary because the one tooth holds your upper partial up. The Plan denied your request. The Plan says your 
benefits for the services have already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefits for the requested services were exhausted on dates of service November 29, 2018, and 
January 10, 2019. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth 
#6 and a core buildup, including any pins when required (D2950) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred by your regular dentist. You 
say that although the dentist is out-of-network you were hoping for at least some contribution towards the cost. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a complete maxillary 
denture (D5110) provided on April 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for the new dentures. 
The Plan denied your request. The Plan says a limited oral evaluation (D0140) and a complete maxillary 
denture (D5110) are not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and a complete maxillary denture (D5110) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) and a partial 
maxillary denture (D5213) provided by an out-of-network provider on November 22, 2021. 
 
You asked the Plan to pay for a complete mandibular denture and a partial maxillary denture. You say that you 
believe that this should be paid. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
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 up to a 
maximum dental allowance amount of $3,500.  
 
We looked at the file and Medicare rules. Evidence was provided that shows that the $3,500 annual benefit 
maximum was met and exhausted. Based on this information, we decided that the Plan's rules for coverage of a 
complete mandibular denture and a partial maxillary denture have not been met. Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) and a partial maxillary denture (D5213) 
provided by an out-of-network provider on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation of periodontal conditions report, probing 
and charting, evaluation and recording (D4269). 
 
You asked the Plan to pre-approve an evaluation of periodontal conditions report. You say that the dentist said 
this is a necessary procedure, and you believe it should be covered under your insurance. The Plan denied your 
request. The Plan says this service is not covered under your contract. 
 
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 an 
evaluation of periodontal conditions report, probing and charting, evaluation and recording (D4269).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and was entirely 
independent prior to hospital admission. You say that the enrollee is unsteady. The Plan denied your request. 
The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as nursing or therapy services at home or in a provider's office. 
 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not have any complex daily wound care, 
parental medications or required care for a new or malfunctioning feeding tube. The enrollee does not require 
skilled nursing and/or skilled therapy services on a daily basis. Although further rehabilitation services would 
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The records 
show that the services were not performed in the inpatient setting. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue exam by a pathologist provided on April 6, 2022, by 
an OON provider. 
 
You asked the Plan to pay for a tissue exam by a pathologist. You say that you are trying to understand why the 
two insurance companies both deny paying for the tissue sample to be analyzed. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
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 tissue exam by a pathologist provided on April 
6, 2022, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need to be able to stay in 
rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, your request for 
approval of continued admission in skilled nursing facility does not meet the requirements for approval. 
 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 pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found You do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in 
a skilled nursing facility (SNF) setting. Your care needs can, as a practical matter, be provided at a lower 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on June 7, 2022, by an out-of-network (OON) provider.