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

 
We decided that the Plan has to pay for an intraoral/panoramic x-ray and comprehensive oral evaluation 
(D0210, D0330, D0150) provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for an intraoral/panoramic x-ray and comprehensive 
oral evaluation (D0210, D0330, D0150) provided on June 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided on November 04, 2020.

You asked the Plan to waive the copayment for radiation therapy. You say that you did not have any services rendered on November 4, 2020. You say that you did have services on November 3, 2020, and those services were processed and paid. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $60 copayment for radiation therapy. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for radiation therapy provided on November 04, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on January 6, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you cannot afford to pay for these 
services and feel the dentist should pay for them because they told you it would be covered. The Plan denied 
your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says 
that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 crown 
(D2740) and core buildup, including any pins when required (D2950) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), and scaling in presence of generalized moderate or severe gingival inflammation 
(D4346) provided on June 1, 2022, and June 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought this treating provider was in-
network, and you would like these services to be paid. 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. 
 
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), complete series of intraoral x-rays (D0210), and scaling 
in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 1, 2022, and 
June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuro degenerative disease risk panel coded as 81405, 
81408, 81320, 81351 provided March 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services in question were clearly 
medically necessary as evidenced by the enclosed requisition form from the treating physician. The Plan denied 
your request. The Plan says the enrollee does not meet criteria. There is no documentation of an uncertain 
diagnosis, and the enrollee has not undergone the conventional diagnostic testing. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of an uncertain diagnosis, and the enrollee has not 
undergone the conventional testing for the diagnosis of Alzheimer's disease (TSH, B12, RPR, electrolytes, MRI 
of the brain). The review has determined that the medical records provided meet the medically necessary 
requirements for Medicare coverage 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuro degenerative disease risk panel coded as 81405, 81408, 81320, 81351 
provided March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing 
(D7922) and the bone replacement graft (D7953) for tooth #14. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary because 
the enrollee has a history of scaling and root planning. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because placement of intra-socket biological dressings and bone 
replacement grafts are 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 the 
placement of intra-socket biological dressing (D7922) and the bone replacement graft (D7953) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
October 19, 2021. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you do not understand the 
difference in radiographic images, and you want the Plan to reconsider payment. 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 pay for a 
panoramic radiographic image (D0330) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone 
replacement graft (D7953) for tooth #31 provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that all dental procedures should be covered under 
your yearly maximum benefit. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because guided tissue regeneration and bone replacement grafts are 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 pay for the 
guided tissue regeneration (D4267) and bone replacement graft (D7953) for tooth #31 provided on April 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are 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 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 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and 
comprehensive oral evaluation - new or established patient (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and need the teeth pulled 
by whoever is covered by the Plan. The Plan denied your request. The Plan says your request for authorization 
for a tooth extraction with an oral surgeon is a non-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. 
 
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 provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth 
and including elevation of mucoperiosteal flap if indicated (D7210), and comprehensive oral evaluation - new 
or established patient (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0366) and consultation (D9310) provided on July 1, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and consultation. You say that you 
had an extreme toothache and your regular dentist's office was closed at the time. You also say that x-rays were 
taken, and it was determined the tooth was infected and had to be removed. The Plan denied your request. The 
Plan says these services are not covered benefits under your dental 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 pay for the cone 
beam computed tomography (CT) capture and interpretation (D0366) and consultation (D9310) provided on 
July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64484-59-RT billed for date of service June 
13, 2022. 
 You asked the Plan to pay for code 64484-59-RT. You say that this service was performed on a different 
anatomical site, so it should be paid. The Plan denied your request. The Plan says payment for this code is 
bundled into payment for code 27093. 
 
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 64484 
is a column II code to column I code 27093 with a modifier indicator of 0. The column II code is therefore not 
payable, even with the 59 modifier appended. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 64484-59-RT billed for 
date of service June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Neuro Degenerative Disease Risk Panel coded as 81443, 
81408, 81320, 81351, 81405 provided March 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services in question were clearly 
medically necessary as evidence by the enclosed requisition form from the treating physician. The Plan denied 
your request. The Plan says This service does not meet the coverage requirements in the applicable Local 
Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has listed diagnoses of unspecified symptoms and signs involving 
cognitive functions and awareness, other symptoms and signs involving cognitive functions and awareness, and 
other amnesia. The enrollee presented for follow-up with a history of ADHD symptoms and depression. It is 
documented that the enrollee would "begin a trial of a SDRI sertraline to achieve a plasma level consistent with 
DA activity as this has proved useful for acute and post-traumatic stress if used as a dual-mechanism agent. 
The enrollee may benefit from other testing including pharmacodynamic and Pharmacokinetic testing." The 
Neuro-degenerative Testing Requisition Form does not specify the testing ordered. The documentation does 
not support that a definitive diagnosis remains uncertain after history, physical examination, pedigree analysis, 
genetic counseling, and completion of conventional diagnostic studies, and that the result of the test will 
directly impact the treatment being delivered to the enrollee. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Neuro Degenerative Disease Risk Panel coded as 81443, 81408, 81320, 81351, 
81405 provided March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on May 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the exam was not 
covered. You say that the exam should be covered. 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 16, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) for teeth numbers 
18 and 19, the surgical placement of implant body (D6010) for teeth numbers 18 and 19, the custom fabricated 
abutment (D6057) for teeth number 18 and 19, a single crown restoration (D6058) for teeth number 18 and 19, 
and bone replacement graft for ridge preservation (D7953) for teeth number 18 and 19. 
 
You asked the Plan to pre-approve the dental services. You say that the Plan claim they have a comprehensive 
dental plan for their customers. You also say the dentist at the office you use does not perform dental surgeries, 
and therefore, you were referred to this requested office. 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. The Plan rules say that 
services obtained from vendors outside this network are not covered. 
 
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 guided 
tissue regeneration (D4266) for teeth numbers 18 and 19, the surgical placement of implant body (D6010) for 
teeth numbers 18 and 19, the custom fabricated abutment (D6057) for teeth number 18 and 19, a single crown 
restoration (D6058) for teeth number 18 and 19, and bone replacement graft for ridge preservation (D7953) for 
teeth number 18 and 19.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive pharmacogenetics panel coded as 81223, 
81240, 81241, 81230, 81291, 81400, 81401, 81408, 81479 and 81406 provided March 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you appreciate reconsideration of this claim 
ask for reversal of the denial of coverage. The Plan denied your request. The Plan says this testing is considered 
unproven and is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical value and effectiveness of comprehensive 
pharmacogenetic testing have not been demonstrated in the peer-reviewed literature. Additionally, this testing 
is not considered a covered screening service per the Medicare Benefit Policy Manual, Chapter 15, Section 
280. 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 comprehensive pharmacogenetics panel 
coded as 81223, 81240, 81241, 81230, 81291, 81400, 81401, 81408, 81479 and 81406 provided March 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction and unspecified diagnostic procedure 
(D0999, D7140) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental 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 
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 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 tooth 
extraction and unspecified diagnostic procedure (D0999, D7140) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346), four gingival irrigations (D4921 x4), and two drugs or medicaments dispensed 
in the office for home use (D9630 x2) provided on March 14, 2022, and April 25, 2022 
 
You asked the Plan to pay for the scaling, gingival irrigations, and drugs or medicaments. You say that these 
services were rendered by an in-network provider. The Plan denied your request. The Plan says these services 
are not covered expenses under your dental 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 pay for the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346), four gingival irrigations 
(D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on 
March 14, 2022, and April 25, 2022