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

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) and the extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) provided on December 28, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
drugs or medicaments dispensed in the office for home use (D9630) and the extraction of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from June 16, 2021, to 
August 16, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not a covered service 
 The Plan must follow Medicare rules. The rules say that for services provided on or after January 21, 2020, 
Medicare offers limited coverage for acupuncture treatments for CLBP up to 12 sessions per 90-day period, 
and no more than 20 sessions per year. 
 
In addition to the approved acupuncture services, the file shows that an office visit, hot/cold pack therapy, 
infrared light therapy, and manual therapy services were provided. We looked at the file and Medicare rules. 
These services are not covered under the acupuncture benefit. Based on this information, we decided that the 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the acupuncture services provided from June 16, 2021, to August 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. The Plan denied your request. The Plan says the SNF 
admission is not shown to be medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a SNF admission. Our reviewer says 
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on August 27, 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 procedure code 00563 is not covered. 
 
The Plan must follow Medicare rules. The rules say that for Medicare purposes, only one anesthesia code is 
reported unless the anesthesia code is an add-on code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 00563 (anesthesia for procedures 
on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest) 
was submitted with code 00560 (anesthesia for procedures on heart, pericardial sac, and great vessels of chest; 
without pump oxygenator). Code 00563 is not an add-on code and cannot be paid separately when billed with 
code 00560. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on 
August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the white filling for a posterior tooth 
(D2393) provided on December 30, 2021. 
 
You asked the Plan to waive the cost share for the dental service. You say that this bill is ridiculous. The Plan 
denied your request. The Plan says the claim was 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, a 
posterior white filling is paid at the rate of a silver filling. The record shows that there is a 50% coinsurance for 
fillings. Additionally, you are responsible for the difference between the allowed amounts. Therefore, we 
decided that the Plan does not have to waive the cost share for the white filling for a posterior tooth (D2393) 
provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight abutment-supported cast metal crowns (D6063) 
and eight implant-supported crowns (D6065). 
 
You asked the Plan to pre-approve implant services. You say that these services are necessary. 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 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 eight 
abutment-supported cast metal crowns (D6063) and eight implant-supported crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urine test (87086) provided on August 18, 
2021. 
 
You asked the Plan to waive the copayment for the urine test. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $15 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $6.46 copayment for the urine test, which is less than the standard $15. Urine 
tests fall 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 a urine test (87086) provided on August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment 
amount is too high. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $325 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services 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 
ambulance transportation provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220), core build up (D2950) and 
crown (D2740) provided on February 28, 2022, by an out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you know this dentist is out of network. You 
say that this is the dentist you wanted to go to for work on your very visible front tooth. You say that this 
dentist was able to fit you in when you were having an emergency. You also say that any financial assistance 
would be appreciated. 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 and crown are 
listed as covered, dental services received out of network are not among those covered under this benefit. 
Additionally, core build up is not covered regardless of the dentist's network status. Therefore, we decided that 
the Plan does not have to pay for the periapical x-ray (D0220), core build up (D2950) and crown (D2740) 
provided on February 28, 2022, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) for tooth #10 and #11 
provided by an out-of-network provider on January 27, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you did not know that there was a benefit 
limit for these services. The Plan denied your request. The Plan says the benefit limit for D2331 has already 
been met and exhausted. 
 
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 one resin-
based composite per tooth every 48 months. 
 
We looked at the file and Medicare rules. Evidence was provided that a resin-based composite was provided on 
March 12, 2020, for tooth #10 and #11. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for a 
resin-based composite (D2331) for tooth #10 and #11 provided by an out-of-network provider on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a septoplasty (30520) provided on January 
19, 2022. 
 
You asked the Plan to waive the copayment for the septoplasty. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $145 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $145 copayment for a septoplasty. Septoplastys fall within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a septoplasty (30520) provided on January 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) and periapical x-ray (D0220) 
provided on December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not know that your plan was changed in 
2018. You say that your tooth broke so you went to the dentist. You say that you do not have the extra money 
to pay this bill. You also say that you would like it to be covered. The Plan denied your request. The Plan says 
the 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction and periapical x-ray are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7140) and periapical x-ray (D0220) provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays provided by a network provider on 
February 1, 2022. 
 
You asked the Plan to pay for the intraoral x-rays (D0210). You say that you have moved away from your last 
dentist and the x-rays were not sent from your previous dentist. You say your new dentist took x-rays. The Plan 
denied your request. The Plan says the service exceeded the frequency limitation in the benefit 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, which includes a maximum benefit of 
one intraoral x-ray (D0210) every three years. The requested services are not covered because the Plan paid for 
intraoral x-rays on October 15, 2020, which exhausted your benefit. Therefore, we decided that the Plan does 
not have to pay for the intraoral x-rays provided by a network provider on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp cap (D3120) provided by an out-of-network provider 
on February 9, 2022. 
 
You asked the Plan to pay for a pulp cap. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental 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 pay for a pulp cap 
(D3120) provided by an out-of-network provider on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on March 
8, 2021.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular risk assessment testing provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), treatment for a root canal 
obstruction (D3331), and endodontic therapy (D3330), provided by a participating provider on November 10, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, treatment for a root canal obstruction, and endodontic 
therapy. You say that the provider should have performed the root canal sooner and as a result, this caused 
unnecessary pain and after affects. The Plan denied your request. The Plan says the services that were provided 
have been 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. The Plan covers two oral 
evaluations per year. The Plan does not cover treatment for a root canal obstruction, and endodontic therapy.  
We looked at the file and Medicare rules. Evidence was provided to show that oral evaluations were provided 
on June 22, 2021, September 8, 2021, September 30, 2021, and on October 28, 2021. Based on this 
information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. 
Treatment for a root canal obstruction and endodontic therapy are not covered dental benefits. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140), treatment for a root canal 
obstruction (D3331), and endodontic therapy (D3330), provided by a participating provider November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary as injections help with your back pain. The Plan denied your request. The Plan says we do 
not see that you had significant benefit from prior injections. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, there is no documentation of the degree and duration of pain relief from previous epidural steroid 
injections. The review has determined that the requested epidural steroid injection does not meet the Medicare 
LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 10, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were in 
excruciating pain on the right side of your mouth. You also say that you could not bite and therefore could not 
eat. 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 contacted the Plan prior to the date of service to verify benefits and provider 
eligibility on December 10, 2021, and you were advised there is no coverage for a problem focused limited oral 
evaluation. 
 
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 
problem focused limited oral evaluation (D0140) provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
as 81404 and 81479 provided December 23, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting a re-determination of the 
denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan says 
diagnosis does not substantiate the service. 
 
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 records show that after outreach to the provider's office, the Plan 
was unable to verify that the ordered the testing for cardiovascular genetics testing.  Genetic cardiovascular 
screening testing does not meet the definition of cardiovascular disease screening as outlined by 42 CFR 
410.17. 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 cardiac risk assessment genetic 
screening testing coded as 81404 and 81479 provided December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia complicated by utilization of controlled 
hypotension services coded 99135 provided on June 30, 2021. 
 
You asked the Plan to pay for the anesthesia complicated by utilization of controlled hypotension services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services billed are not separately payable. 
 
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, the CPT Code Manual definition of code 99135 is anesthesia complicated by utilization of 
controlled hypotension (List separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99135 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". This means that payment for these services is always bundled into payment for other services 
not specified, and no separate payment can be made. Based on this information, we decided that Medicare rules 
for coverage of the anesthesia complicated by utilization of controlled hypotension services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia complicated by utilization of 
controlled hypotension services coded 99135 provided on June 30, 2021.