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

 
We decided that the Plan does not have to pay for extractions (D7140 x 6), surgical extractions (D7210 x 3), 
and immediate dentures (D5130) provided on March 3, 2022. 
 
You asked the Plan to pay for extractions and dentures. You say that you have diabetes, and your teeth were 
decaying so they needed to be removed. You also say you need the dentures for health reasons. The Plan 
denied your request. The Plan says two extraction procedures are covered by the Plan's dental benefits per 
calendar year; however, your benefit for two extractions has been exhausted. The Plan also says that immediate 
dentures (D5130) 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 Plan's coverage rules apply in this case. The Plan covers two 
extraction (D7140, D7210) procedures per calendar year. 
 
We looked at the case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for two 
extraction procedures provided on March 3, 2022, which were included on the same claim as the denied 
services. Therefore, the benefit for extractions have been exhausted. Though the Plan offers a dental benefit 
in excess of Medicare coverage, the immediate dentures (D5130) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for extractions (D7140 x 6), surgical extractions 
(D7210 x 3), and immediate dentures (D5130) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the general dentist office visit with an OON provider. 
 
You asked the Plan to pre-approve general dentist office visit. You say that there are no in-network dentist 
within your area. The Plan denied your request. The Plan says the requested service is available in-network and 
a list of in-network providers that is within the allowable distance was given to the enrollee. 
 
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 when receiving them from an OON provider. Therefore, we decided 
that the Plan does not have to pre-approve the general dentist office visit with an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain crowns for teeth #23 and 
#26 (D6065), porcelain/ceramic pontics on teeth #24 and #25, and custom-fabricated abutments on teeth #23, 
and #26 to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the implant supported porcelain crowns on teeth #23 and #26 (D6065), 
porcelain/ceramic pontics on teeth #24 and #25 (D6245), and the custom-fabricated abutments on teeth #23 and 
#26. You say that you are requesting reconsideration of the request. 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 implant supported porcelain crowns 
on teeth #23 and #26 (D6065), porcelain/ceramic pontics on teeth #24 and #25 (D6245), and the custom-
fabricated abutments on teeth #23 and #26 are not among those covered under this benefit. The record shows 
that the requested dentist is out-of-network. Therefore, we decided that the Plan does not have to pre-approve 
implant supported porcelain crowns for teeth #23 and #26 (D6065), porcelain/ceramic pontics on teeth #24 and 
#25, and custom-fabricated abutments on teeth #23, and #26 to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 23, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 23, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 23, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of June 23, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond June 23, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 23, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 23, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) dental services provided on January 26, 2022. 
 
You asked the Plan to pay for the core buildup. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 core 
buildup (D2950) dental services provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for observation (during regularly scheduled 
hours) - no other services performed (D9430) July 21, 2020. 
 
You asked the Plan to pay for the office visit for observation. You say that you cannot afford the cost of this 
service. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the office 
visit for observation (during regularly scheduled hours) - no other services performed (D9430) July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services (75710-59) provided on January 4, 2022. 
 You asked the Plan to pay for the angiography services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no payment can be made for code 75710-
59 as its billing is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 75710 is a column II code to column I code 37236; however, 75710 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the angiography services. Our reviewer says that the 
documentation does not support payment for the services billed. Our reviewer found the documentation 
submitted was reviewed, and the criteria for coverage have not been met. This procedure would be inclusive to 
CPT 37236, which per CPT code description "including radiological supervision and interpretation" and 
therefore would not be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the 
Plan does not have to pay for the angiography services (75710-59) provided on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic cover and alignable system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
approved items will meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  We looked at the file and Medicare rules. A protective outer surface covering system was requested. The records do not show that the enrollee has a need for protection against an unusually harsh environment, or that 
the approved covering will not be adequate. A below knee endoskeletal alignable system was requested. This 
item was approved in May 2020. There are no records to show that the current item is unable to be used with 
the approved prosthesis. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
prosthetic cover and alignable system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and bitewings-four radiographic images 
(D0274) provided on March 22, 2022. 
 
You asked the Plan to pay for prophylaxis (D1110) and bitewings-four radiographic images (D0274). You say 
that you were not aware these services were not covered by your insurance. The Plan denied your request. The 
Plan says this service is not covered under your 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 prophylaxis and 
bitewings-four radiographic images were not covered under Original Medicare. Therefore, we decided that the 
Plan does not have to pay for prophylaxis (D1110) and bitewings-four radiographic images (D0274) provided 
on March 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 3, 
2021, to June 1, 2021. 
 
You asked the Plan to pay for the SNF care provided from May 14, 2021, to June 1, 2021. You say that the 
services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did 
not require daily skilled care on the date of service in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care provided from May 14, 2021, 
to June 1, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care provided from May 14, 2021, to June 1, 2021 have not been met. 
Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided 
from May 3, 2021, to June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of autologous blood 
concentrate products (D7921 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under your 
contractual policy. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
collection and application of autologous blood concentrate products (D7921).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Caris Genomic Prevalence Score (GPSal) testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the denial of authorization for this testing is correct, because the 
clinical value and effectiveness of this testing in the setting of Stage IV adenocarcinoma of the pancreas have 
not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found pancreatic cancer has been a notably difficult cancer to treat. With the emergence of new agents 
to treat pancreatic cancer, particularly biologics, clinical trial strategies incorporating principals of molecular 
biology and new imaging methods as results from pre-clinical studies are important. Per guidelines, 
tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease who are 
candidates for anti-cancer therapy to identify uncommon mutations. This can help identify available therapies 
and eligibility for clinical trials. This is a standard 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve Caris Genomic Prevalence Score (GPSal) testing.  
 
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 resin-based composite - one surface, anterior (D2330) 
and prefabricated abutment - includes modification and placement (D6056) provided February 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based filling and prefabricated abutment. You say that you feel your 
annual maximum should cover the cost of these services. The Plan denied your request. The Plan says the OON 
cost-sharing was applied correctly to the filling and the abutment is not a covered 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. For services obtained Out-of-Network the Plan only pays up to a certain amount. If you choose to see an Out-of-Network dentist you might 
be billed by that provider for any amount greater than what the Plan pays, even for services listed as $0 
copayment. 
 
We looked at the file and Medicare rules. In this case the services were provided OON. The Plan provided 
documentation showing that they have paid the full allowed amount for the filling. You have been asked to pay 
the difference between the Plans allowed amount and the total cost billed by the OON provider. This means 
you have been asked to pay the correct amount based on your contract with the Plan. Though the Plan offers 
dental benefits in excess of Medicare coverage, the prefabricated abutment is not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, 
anterior (D2330) and prefabricated abutment - includes modification and placement (D6056) provided 
February 1, 2022, 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 occlusal guard (D9944) provided by a network provider 
on January 5, 2022. 
 
You asked the Plan to pay for the occlusal guard (D9944). You say that you have extensive temporal-
mandibular joint (TMJ) pain caused by grinding your teeth while sleeping. You say that eating a normal meal is 
difficult and painful. 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. The Plan covers the occlusal 
guard (D9944) 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 pay for the occlusal guard (D9944). Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation provided 
does not meet the criteria for coverage for an oral appliance for treatment of the enrollee's TMJ pain. The 
normal course of treatment prior to appliance therapy is soft diet, warm compresses, exercises and non-steroidal anti-inflammatory drugs (NSAIDS) when appropriate. There was no indication that these protocols 
were employed. Also, no diagnosis of a medical condition as the etiology of the condition has been stated. 
 
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 the occlusal guard (D9944) have not been met. Therefore, we decided that the 
Plan does not have to pay for the occlusal guard (D9944) provided by a network provider on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided on 
June 7, 2022. 
 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 was not billed in accordance 
with Medicare billing 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 and 81292) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant services (D4266, D6011, D6104). 
 
You asked the Plan to pre-approve the dental implant services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall under your dental coverage. 
 
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 pre-approve 
dental implant services (D4266, D6011, D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided by a non-participating 
provider on September 16, 2021. 
 
You asked the Plan to pay for the extraction (D7140). You say that you were not informed that the provider 
became out-of-network as of August 31, 2021. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction (D7140) is not among 
those covered under this benefit, regardless of provider network status. Therefore, we decided that the Plan 
does not have to pay for the extraction (D7140) provided by a non-participating provider on September 16, 2021.