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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on November 11, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were told that this Plan would 
cover everything. The Plan denied your request. The Plan says the benefit limit has already been exhausted for 
a comprehensive 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. The Plan covers a 
comprehensive oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on July 29, 
2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided by a participating provider on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on February 25, 2021. 
 
You asked the Plan to pay for the lab service. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. This claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab service have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab service provided on February 25, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for these services. We decided that the Plan does not have to pay for the 
services described by codes 75726-26-59 and 75774-26-59.  
 
You asked the Plan to pay for these services. You say that it is felt that these services were correctly billed and 
should be paid. The Plan says that no decision was about regarding 36253; however, 75726 and 75774 are 
inclusive to code 37244. 
 
We decided that the Plan has to pay for the services described by 36253-LT.  
 
The Plan follows 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. 
 
The Plan neglected to provide a denial rationale for this service. The service was denied payment along with 
the other codes billed on this claim. Since the Plan forfeited the opportunity to provide a valid denial rationale, 
we find that the denial is not substantiated. Based on this information, we decided that Medicare rules for 
coverage of the services described by 36253-LT have been met. Therefore, we decided that the Plan has to pay 
for the services described by 36253-LT.  
 
We also decided that the Plan does not have to pay for the services described by codes 75726-26-59 and 
75774-26-59.
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Codes 75726 and 75774 are Column 2 codes in relation to code 37244. Both codes were reported with a 
modifier which would allow the edit to be bypassed. 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine whether the use of modifier -59 was clinically appropriate, and if the Plan was correct in denying the 
request to pay for these codes.  Our reviewer says that the documentation does not support that the services billed with 75726 and 75774 are separately payable from 37244. Our physician reviewer found the procedure report does not support any 
diagnostic angiograms were performed before the intervention, and therefore 75726 and 75774 would be 
inclusive to CPT 37244.   
 
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 services described by codes 75726-26-59 and 75774-26-59. have not been 
met. Therefore, we decided that the Plan does not have to pay for the services described by codes 75726-26-59 
and 75774-26-59. 
 
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 endosteal implants (D6010), diagnostic casts (D0470), 
and the custom fabricated abutment (D6057) provided by a network provider from February 5, 2021, to May 
19, 2021. 
 
You asked the Plan to pay for the endosteal implants (D6010), the diagnostic casts (D0470), and the custom 
fabricated abutment (D6057). You say that you are appealing these claims. 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 endosteal implants (D6010), the 
diagnostic casts (D0470), and the custom fabricated abutment (D6057) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the endosteal implants (D6010), 
diagnostic casts (D0470), and the custom fabricated abutment (D6057) provided by a network provider from 
February 5, 2021, to May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial denture (D5820) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve interim partial denture. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D5820 is not a covered 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 
interim partial denture (D5820) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 22 and 27. 
 
You asked the Plan to pre-approve the retainer crowns. You say that these crowns are medically necessary to 
complete the treatment. The Plan denied your request. The Plan says this service is not covered under your 
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, 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 
retainer crowns (D6750) for tooth #'s 22 and 27.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on June 21, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were considered medically 
necessary. The Plan denied your request. The Plan says the codes are included in the payment made to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services 
to the beneficiary either directly or under arrangements made with outside providers.  
 
We looked at the file and the rules. The services at issue were provided via arrangement of the facility. 
Payment for the services would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility. 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 perfusion services 
provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you received on 
November 30, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you switched dentists and the new 
dentist did not advise you that they were providing services that would not be covered. You believe this should 
be covered because the dentist was looking out for your dental health. The Plan denied your request. The Plan 
says you already had a covered comprehensive oral exam that the Plan paid for on March 18, 2021. You were 
not eligible for another comprehensive oral exam when you had the service on November 30, 2021. 
 
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 contract explicitly 
states that comprehensive oral exams (code D0150) are only covered once every three years.  You already 
received a covered comprehensive oral exam on March 18, 2021, so you were not eligible for coverage for the one you had on November 30, 2021. This coverage rule applies regardless of the appropriateness of the service. 
 
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 pay for the 
comprehensive oral exam (code D0150) you received on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266), the removal of residual 
tooth roots (D7250), and a bone replacement graft (D7953) provided by an out-of-network provider on March 
18, 2021. 
 
You asked the Plan to pay for a guided tissue regeneration, the removal of residual tooth roots, and a bone 
replacement graft. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan 
says the rendered dental 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 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 guided tissue regeneration (D4266), the removal of residual tooth roots (D7250), and a bone replacement graft (D7953) provided by an out-of-network provider on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two custom fabricated abutments (D6057 x2), two abutment supported porcelain fused to 
metal crowns (D6059 x2), two bone replacement grafts for ridge preservation (D7953 x2), and a pontic 
(D6245) for tooth #14. 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments, abutment supported 
porcelain fused to metal crowns, bone replacement grafts, and pontic. The Plan denied your request. The Plan 
says the endosteal implants, custom fabricated abutments, abutment supported porcelain fused to metal crowns, 
and two bone replacement grafts are not covered under your benefit plan. The Plan also says that the pontic is 
not medically necessary. 
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 pontics when 
the services are medically necessary and reasonable, and are not associated with dental implants.  
 
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 the pontic. Our reviewer says that there 
is no coverage under the Plan and there is no necessity for the requested pontic. Our physician reviewer found 
the Plan provisions only allow for fixed bridges in the anterior segment of the mouth, and only if there are no 
missing posterior teeth. The Plan does not provide for implant services of any kind. Our reviewer found that in 
this instance the requested pontic is for use in an implant supported posterior bridge. Neither implant services 
nor posterior bridgework are covered services. Our physician reviewer also found that the requested pontic is 
for a posterior tooth, and would be part of an implant supported bridge. 
 
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 endosteal implants, custom fabricated abutments, abutment supported 
porcelain fused to metal crowns, bone replacement grafts, and pontic have not been met. Therefore, we decided 
that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants 
(D6010 x2), two custom fabricated abutments (D6057 x2), two abutment supported porcelain fused to metal 
crowns (D6059 x2), two bone replacement grafts for ridge preservation (D7953 x2), and a pontic (D6245) for 
tooth #14.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an echocardiography, cardiovascular stress 
test, and a comprehensive metabolic panel provided on October 29, 2021. 
 
You asked the Plan to waive the copayments for an echocardiography, cardiovascular stress test, and a 
comprehensive metabolic panel. You say that you were told from your insurance company and the hospital 
there would be no copayment for these tests, otherwise you would not have had the tests done. 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 $35 
copayment for basic imaging services, including echocardiography. The Plan contract also says that enrollees 
must pay a $200 copayment for advanced imaging services, including stress tests. The Plan contract also says 
that enrollees must pay a $5 copayment for diagnostic lab services. 
 
You have been asked to pay a $35 copayment for an echocardiography. You have also been asked to pay a 
$200 copayment for a cardiovascular stress test. You have also been asked to pay a $5 copayment for a 
comprehensive metabolic panel. You have been asked to pay a total of $240 ($35 + $200 + $5 = $240). An 
echocardiography, cardiovascular stress test, and a comprehensive metabolic panel 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 copayments for an echocardiography, cardiovascular stress test, and a comprehensive metabolic panel 
provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), bitewing x-rays (D0274) prophylaxis (D1110), and amalgam (D2160) provided on November 
3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, 
prophylaxis, and amalgam. You say that you were not aware that you needed to see an in-network provider for 
the visit to be covered. The Plan denied your request. The Plan says these services were rendered by 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 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 periodic 
oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0274) prophylaxis 
(D1110), and amalgam (D2160) provided on November 3, 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 removal of residual tooth roots (D7250) provided by a 
participating provider on November 29, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that you were under the impression 
that these services would be covered. The Plan denied your request. The Plan says D7250 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 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 
removal of residual tooth roots (D7250) provided by a participating provider on November 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90837) provided on July 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that you have rendered treatment to the patient in good faith that the service will get reimbursed, and the service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says the services are not authorized because the provider is a non-network provider who does not work with the Plan, and the member was referred by her non-participating outpatient nursing facility. The Plan also says that the member's primary care physician (PCP) did not reefer for services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy (90837) provided on July 9, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on November 3, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this 
procedure is inclusive to the main procedure. 
 
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 75726 is angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation. 
 
We looked at the file and the rules. We find that the radiology service is inclusive of another procedure 
provided on the same date of service. Providers must bill with the most comprehensive code to describe the 
services provided. 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 the angiography 
services provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 22, 2021. 
 
You asked the Plan to pay for dental services. You say that your son won't let you brush his teeth because of 
the pain. The Plan denied your request. The Plan says services provided by an out-of-network provider are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services when the services are provided by a participating provider. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical radiographic image (D0230), and 
pulp vitality tests (D0460) provided by a participating provider on August 26, 2021, to September 2, 2021. 
 
You asked the Plan to pay for an additional periapical radiographic image and pulp vitality tests. You say that 
you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0230 
has already been exhausted. The Plan says that D0460 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
additional periapical radiographic image (D0230), and pulp vitality tests (D0460) provided by a participating 
provider on August 26, 2021, to September 2, 2021.