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

 
We decided that the Plan does not have to pay for the repair of broken denture (D5512) provided on August 16, 
2021, and the limited oral exam (D0140) and palliative (emergency) treatment of dental pain (D9110) provided 
on September 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were emergent and should be 
covered. The Plan denied your request. The Plan says these services are not covered by your dental 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 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 repair 
of broken denture (D5512) provided on August 16, 2021, and the limited oral exam (D0140) and palliative 
(emergency) treatment of dental pain (D9110) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
 We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray 
(D0330), and removal of residual tooth roots (D7250) provided on May 10, 2021 by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says routine dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare.  Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray (D0330), and removal of residual tooth roots (D7250) provided on May 10, 2021 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) 
provided on October 21, 2021. 
 
You asked the Plan to pay for the bitewing x-rays and prophylaxis. You say that these procedures were 
performed under two different policies, and you feel that the enrollee was entitled to benefits under each plan. 
You also say that you feel the benefits of each plan should be honored and that the Plan pay for these services. 
The Plan denied your request. The Plan says the enrollee's benefits for these services have been satisfied and 
the frequency limitations have 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, bitewing x-rays are limited to one set 
per calendar year, and prophylaxis is limited to one procedure code per calendar year. The record shows that 
the enrollee received bitewing x-rays (D0274) and a prophylaxis (D1110) on March 8, 2021 and the enrollee's 
bitewing x-rays and prophylaxis benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning, all four quadrants (D4341) 
with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve deep gum and root cleaning, all four quadrants with an OON provider. You 
say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental 
services are not covered by the Plan when provided by an out-of-network provider. 
 
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 out-of-network provider. Therefore, we decided 
that the Plan does not have to pre-approve deep gum and root cleaning, all four quadrants (D4341) with an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional procedures to customize a crown to fit 
under an existing partial denture framework (D2971 x2). 
 
You asked the Plan to pre-approve the additional procedures to customize a crown. You say that you feel that 
the Plan is being dishonest by not approving this service. You also say that you feel this service should be 
covered because it is crown related and crowns are a covered service. The Plan denied your request. The Plan 
says this service is not covered on your plan. 
 
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 two 
additional procedures to customize a crown to fit under an existing partial denture framework (D2971 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry services provided on April 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing was needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the service cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated 
is not separately billable. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for mass 
spectrometry services provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry rendered on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 2. You billed 20 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the 
immunohistochemistry rendered on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition (D8090) and periodic orthodontic treatment visit (D8670). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment of the adult dentition and periodic 
orthodontic treatment visit. You say that you urgently need this treatment. You also say that these services are 
not for aesthetics but for health reasons. The Plan denied your request. The Plan says these services are non-
covered benefits 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 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 a 
comprehensive orthodontic treatment of the adult dentition (D8090) and periodic orthodontic treatment visit 
(D8670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on November 1, 2021. 
 
You asked the Plan to pay for the consultation. You say that you went to an out-of-network provider because 
you had no other choice. You also say that your primary dentist advised you be examined by an endodontist 
because a root canal may be necessary. The Plan denied your request. The Plan says this service is not a 
covered expense 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 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 the 
consultation (D9310) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on March 25, 2021. 
 
You asked the Plan to pay for the supply allowance. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the records do not support the billed 
equipment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical records do not support that the member's physician discussed the use of a 
CGM. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair front and rear lights, kit, and shroud 
fender (K0108). 
 
You asked the Plan to pre-approve the wheelchair front and rear lights, kit, and shroud fende. You say that the 
items are medically necessary. The Plan denied your request. The Plan says these items do not primarily serve 
a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the wheelchair front and rear lights, kit, and shroud fender 
(K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and crown (D2740) provided 
from August 24, 2021, and September 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the core buildup, periodic oral evaluation, bitewing x-rays, prophylaxis, and 
crown. You say that you would like these services to be covered because your dentist stated that they do accept 
your insurance and are in-network. The Plan denied your request. The Plan says these services were rendered 
by an OON provider, and no prior authorization was requested to see this provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950), periodic oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110), and crown (D2740) provided from August 24, 2021, and September 13, 2021 
by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on April 30, 2021. 
 
You asked the Plan to pay for the observation care discharge day management. You say that you would like 
this claim to be reviewed for payment. The Plan denied your request. The Plan says Original Medicare would 
be responsible for payment of all Medicare covered services related or unrelated to the enrollees terminal 
condition. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 29, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that the POS rules used by the Plan only apply 
to lab tests paid under the Physician Fee Schedule. POS 81 is correct for this test. The Plan denied your request. 
The Plan says the claim was not billed with the POS code of where the sample was taken. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and 
panoramic x-ray (D0330) provided on November 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, 
and panoramic x-ray. You say that when you called to make a reservation you were informed that his practice 
accepts your insurance. The Plan denied your request. The Plan says these services were rendered by an OON 
provider. The Plan also says that you did to go this provider's office to see an in-network provider, but when 
you arrived the in-network provider was no longer available, and you chose to see an OON provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), additional intraoral periapical 
x-ray (D0230), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on November 22, 2021 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 limited oral evaluation (D0140) and panoramic x-ray 
(D0330) provided on October 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that any assistance towards this claim would be 
greatly appreciated. The Plan denied your request. The Plan says routine dental services are not covered by 
Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140) and panoramic x-ray (D0330) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the scaling and planing. You say that due to the COVID-19 lock-down you could 
not get a regular teeth cleaning for two years which is why this procedure was necessary. The Plan denied your 
request. The Plan says this procedure is not a benefit under the dental plan. 
 
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 the 
periodontal scaling and root planing (D4341) provided on November 3, 2021.