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

 
We decided that the Plan has to pay for the laboratory services (87633) provided on December 28, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services (87633) provided on December 28, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
You asked the Plan to pre-approve a portable home ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no evidence of chronic CO2 retention and Bipap with AVAPS has not been tried. Usage data indicates the patient is not using the ventilator enough to be effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81408, 81162, 81292, 81321 and 
81407) provided on October 15, 2021.  
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 these services have been billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results. 
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. 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 (81408, 81162, 81292, 81321 and 81407) provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4267) to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the gum surgery (D4267). You say that the service is highly recommended 
together with the osseous surgery for better results and longevity of the existing teeth. You say the service is 
medically necessary. The Plan denied your request. The Plan says the service is not a covered 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 gum surgery (D4267) is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gum surgery 
(D4267) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions to be performed by a prosthodontist. 
 
You asked the Plan to pre-approve dental extractions to be performed by a prosthodontist. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has 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 states that covered 
services must be performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental extractions to be performed by a prosthodontist have not been met. Therefore, we decided 
that the Plan does not have to pre-approve dental extractions to be performed by a prosthodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that your dentures no longer fit 
causing food to go underneath the denture. You need a replacement denture but need the soft tissue repaired 
because it causes a lot of pain. The provider cannot do the replacement denture without this procedure. The 
Plan denied your request. The Plan says the procedure code is not listed and therefore is not covered by the 
Plan. 
 
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 
incisional biopsy of oral tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation 
(D0150), prophylaxis (D1110), and bitewing x-rays (D0274) provided on January 5, 2022, by the out of 
network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the dental office advised 
you would not have to pay additional fees not covered by your plan. You say that received a bill with an 
exorbitant fee. You say that you are not in the position financially to pay this. You also say that you only 
received x-rays. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan paid the provider. Therefore, 
we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274) provided on January 5, 2022, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) and x-rays (D0210) 
provided January 18, 2022. 
 
You asked the Plan to pay for the oral exam and x-rays. You say that this service should be covered because 
you were required to see a new dentist. The Plan denied your request. The Plan says these services are only 
covered once every three 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are only 
covered once every three years. The record shows you previously received a comprehensive oral exam and 
complete intraoral radiographs on February 3, 2020. Therefore, we decided that the Plan does not have to pay 
for a comprehensive oral exam (D0150) and x-rays (D0210) provided January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement crown (D2920) provided by an out-of-network 
provider on January 19, 2022. 
 
You asked the Plan to pay for the recement crown (D2920). You say that you have used your dental group for 
your entire life. You say the Plan should pay the claim and you should have an exemption for life. The Plan 
denied your request. The Plan says you pay 100% for out-of-network services. 
 
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 recement crown (D2920) not 
among those covered under this benefit when rendered by an out-of-network provider. The record shows the 
provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the recement crown 
(D2920) provided by an out-of-network provider on January 19, 2022.  
 Your complaint about the indited in-network dentist 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 pay for the limited oral evaluation (D0140) provided on February 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist due to experiencing 
extreme pain and toothache. You say that you were referred to an endodontist for further consult. You also say 
that the services were medically necessary. The Plan denied your request. The Plan says 1 limited oral 
evaluation is covered per plan year. The Plan also says that the frequency limit 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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on February 3, 2022. The record also shows that the claim for the date of service 
in this case was received after the claim for February 3, 2022. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and bone 
replacement graft for ridge preservation - per site (D7953) provided December 20, 2021. 
 
You asked the Plan to pay for the surgical tooth extraction and bone replacement graft. You say that you were 
not told that the bone graft would not be covered. The Plan denied your request. The Plan says the claims have 
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. The Plan covers the tooth 
extraction with 50% coinsurance after your $100 deductible has been met.   
We looked at the file and Medicare rules. In this case the contracted rate for the surgical tooth extraction was 
$92.50. This amount was applied to your deductible. The remaining cost over the contracted rate is your 
responsibility. Though the Plan offers dental benefits in excess of Medicare coverage, the bone replacement 
graft is not among those covered services. Based on this information, we decided that the Plan's rules for 
coverage of the surgical tooth extraction and bone replacement graft have not been met. Therefore, we decided 
that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and bone replacement graft for 
ridge preservation - per site (D7953) provided December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Surgical trays (A4550) provided on December 13, 2021. 
 
You asked the Plan to pay for code A4550. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code A4550 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code A4550 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for the Surgical 
trays (A4550) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940) and the first periapical x-
ray (D0220) provided by an out-of-network provider on November 23, 2021, and December 6, 2021. 
 
You asked the Plan to pay for the protective restoration (D2940) and the first periapical x-ray (D0220). You 
say that you are resubmitting your updated bill since it was denied the last time. The Plan denied your request. 
The Plan says the services are not covered 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 protective restoration (D2940) and 
the first periapical x-ray (D0220) are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the protective restoration (D2940) and the first periapical x-ray (D0220) 
provided by an out-of-network provider on November 23, 2021, and December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 25, 2021. 
 
You asked the Plan to pay for the dental service. You say that your dentist advised you needed to see an oral 
surgeon. The Plan denied your request. The Plan says a limited oral evaluation is covered once per plan year. 
The Plan also says that the frequency limit 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 and 1 limited oral evaluation is covered 
per year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on October 6, 2021.  
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic drug injection (D9612). 
 
You asked the Plan to pre-approve a therapeutic drug injection. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 pre-approve a 
therapeutic drug injection (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210), and the removal of residual tooth 
roots (D7250), provided by a participating provider on December 27, 2021. 
 
You asked the Plan to pay for an extraction and the removal of residual tooth roots. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the services being denied are not 
covered 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 an 
extraction (D7210), and the removal of residual tooth roots (D7250), provided by a participating provider 
December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0140, D0367, D6190) provided November 
15, 2021 to December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the provider has opted out of Medicare and is 
not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services (D0140, D0367, D6190) provided November 15, 2021 to December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292, 81301) provided 
on October 13, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed correctly 
based on the Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292, 81301) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the additional periapical x-rays (D0230 x 2) 
provided on February 7, 2022. 
 
You asked the Plan to reimburse you for the dental services. You say that the services should be covered. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 and periapical x-ray is listed as 
covered, the frequency limit of 1 per calendar year has been exceeded. The record shows that the Plan paid for 
the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the 
Plan does not have to reimburse you for the additional periapical x-rays (D0230 x 2) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you have dialysis 3 times a week 
which is necessary for you to live. You also say that you have no close family who can drive you to these 
appointments, nor do you have enough money to pay for transportation. The Plan denied your request. The 
Plan says you have exhausted the established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954), and endodontic 
therapy (D3320), provided by a participating provider on December 8, 2021. 
 
You asked the Plan to pay for a prefabricated post and core, and endodontic therapy. You say that you were 
unaware that these services were not covered. The Plan denied your request. The Plan says the rendered 
services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a prefabricated post and core (D2954), and endodontic therapy (D3320), provided by a participating provider on December 8, 2021.