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

 
We decided that the Plan does not have to pay for the bone replacement graft  retained natural tooth  first site 
in quadrant (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), pontics - porcelain fused 
to predominantly base metal (D6241) and extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided January 21, 2022. 
 
You asked the Plan to pay for the bone replacement graft, guided tissue regeneration, pontics and tooth 
extraction. You say that these services were medically necessary to treat an infection and should be covered 
under your medical benefit. The Plan denied your request. The Plan says the claims have 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. The Plan covers two 
extractions per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that 2 tooth extractions 
were covered on the same date of service. This means that the third extraction exceeds the Plans frequency 
limit and is not covered. Though the Plan offers dental benefits in excess of Medicare coverage, the bone 
replacement graft, guided tissue regeneration and pontics are not among those covered services.  Therefore, we 
decided that the Plan does not have to pay for the bone replacement graft  retained natural tooth  first site in 
quadrant (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), pontics - porcelain fused to 
predominantly base metal (D6241) and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided January 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Multianalyte Assays with Algorithmic Analyses (81599) provided 
November 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the test was denied in error 
and you are requesting it to be reprocessed and paid. The DecisionDX-SCC test is a covered Medicare benefit. 
The Plan denied your request. The Plan says that coverage/program guidelines were not met. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not substantiated their reason to deny payment for the services. The 
Plan denied for coverage/program guidelines have not been met. This Plan has not directly addressed their 
reason to deny. Therefore, we decided that the Plan has to pay for Multianalyte Assays with Algorithmic 
Analyses (81599) provided November 29, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk ankle/foot system described by code L5981 
and a below-the-knee endoskeletal addition, alignable system described by code L5910. 
 
You asked the Plan to pre-approve the two prosthetic component codes. You say that this should be approved. 
The Plan denied your request. The Plan says all requested items were approved aside from L5981 and L5910. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components are covered based on the 
enrollee's functional level with limitations on what can be replaced while under warranty. These criteria are 
described in the Medicare rules section of this decision. 
 
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 two prosthetic component codes. 
Our reviewer says that the requested components do not meet Medicare criteria. Our physician reviewer found 
tn this case, the documentation indicates that the member is a level 2 ambulator and is requesting replacement 
prosthesis due to his current prosthesis no longer fitting. The health plan has authorized a replacement socket 
but notes the foot is still under warranty, and the alignable system can be used with the new socket. The 
requested items are not medically necessary. 
 
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 two prosthetic component codes have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a flex-walk ankle/foot system described by code L5981 and a below-
the-knee endoskeletal addition, alignable system described by code L5910.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on September 16, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 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 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.74 
Genvisc Drug $411.00 $205.50 
Total:  $289.08 
 
You have been asked to pay $289.08, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug falls within the Medicare Part B Prescription Drugs 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 coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation treatment provided on March 
7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulation treatment. You say that the service is medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
chiropractic manipulation treatment. We found no exception that would require the Plan to pay for these 
items/services. The records provided for review do not show that the service at issue was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulation treatment provided 
on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection component (E2311) for a 
power wheelchair. 
 
You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested item have not been met. 
 
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 pre-approve an electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection component (E2311) for a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 At-Home Test Kit provided on 
January 1, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 At-Home Test Kit. You say that were advised in January 
that these kits would be covered as long as you pay out of pocket and submit for reimbursement. You say that 
you were not advised these kits would not be covered until February 1, 2022. The Plan denied your request. 
The Plan says the COVID-19 At-Home Test Kit is not covered until February 1, 2022. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 At-Home Test Kit have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for a COVID-19 At-Home Test Kit on January 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit and triamcinolone 
acetonide joint injection provided by an out-of-network (OON) provider on November 3, 2020. 
 You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 50% 
coinsurance for specialist visits with an out-of-network (OON) provider. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for surgery or services at an 
out-of-network (OON) outpatient hospital or ambulatory surgical center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Specialist Visit $101.55 $50.78 
Injection Procedure $58.56 $29.28 
Fluoroscopic Guidance $100.18 $50.09 
Triamcinolone Acetonide Drug $5.32 $2.66 
Total:  $132.81 
 
You have been asked to pay $132.81, which is 50% of the allowed amount for the OON office visit and 
injection with fluoroscopic guidance. The office visit falls within the Physician/Practitioner Services, Including 
Doctor's Office Visits benefit category. The injection procedure falls within the Outpatient Surgery, Including 
Service Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The 
fluoroscopic guidance falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The triamcinolone acetonide drug falls within the Medicare Part B Prescription Drugs 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 coinsurance for a specialist office visit and triamcinolone 
acetonide joint injection provided by an out-of-network (OON) provider on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on January 27, 2022. 
 
You asked the Plan to pay for an evaluation, prophylaxis, and x-rays. You say that you were told services were 
covered by this provider. The Plan denied your request. The Plan says a periodic oral evaluation (D0120) and 
prophylaxis (D1110) are not covered when seen by a non-participating provider. Bitewing x-rays (D0274) are 
not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received dental services from a non-participating provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit or not covered when received by a non-participating provider. Therefore, we decided that the Plan 
does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) 
provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the refraction services (92015) provided December 13, 2021. 
 
You asked the Plan to pay for the vision services. You say that you paid $40 copay and a payment of $30 for 
refraction totaling $70. The Plan denied your request. The Plan says that the provider is in network for 
supplemental vision benefit but is out of network for medical services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
In this case, the records show that the enrollee received vision services from the provider. The records also 
show that the Plan paid for the vision services per the Explanation of Benefits dated December 16, 2021 as the 
provider is an in network provider for supplemental vision benefits. Notes from the case file also indicate that 
the enrollee has no financial responsibility as the refraction is included in the routine examination. The file 
does not show that the Plan provided notice that the vision services would not be covered. Under Medicare 
rules, this means the vision services is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for the refraction services (92015) provided December 13, 2021.  
 
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 single radiographic image, surgical procedure for isolation of 
tooth with rubber dam, Therapeutic Parenteral Drug-Single Administration, and treatment of root canal 
obstructions (D0270, D3910, D3331). 
 
You asked the Plan to pay for the single radiographic image, surgical procedure for isolation of tooth with 
rubber dam, Therapeutic Parenteral Drug-Single Administration, and treatment of root canal obstructions. You 
say that the services should be reimbursed as you disagree with the charges. The Plan denied your request. The 
Plan says the reimbursement request denied correctly as the services 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 single 
radiographic image, surgical procedure for isolation of tooth with rubber dam, Therapeutic Parenteral Drug-
Single Administration, and treatment of root canal obstructions (D0270, D3910, D3331).
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  full mouth, after oral evaluation (D4346) provided February 24, 2022. 
 
You asked the Plan to pay for the scaling in presence of generalized moderate or severe gingival inflammation. 
You say that you were not aware that there are different levels of teeth cleaning. The Plan denied your request. 
The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
scaling in presence of generalized moderate or severe gingival inflammation  full mouth, after oral evaluation 
(D4346) provided February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010). 
 
You asked the Plan to pre-approve endosteal implants. You say that you were told the implants would be 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implants (D6010).  
 
Your complaint about potentially being provided misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0380) provided on January 26, 2022. 
 
You asked the Plan to pay for imaging. You say that this imaging was medically necessary. The Plan denied 
your request. The Plan says that cone beam imaging (D0380) is not covered by your Plan's routine 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 cone 
beam imaging (D0380) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (dental code D0140) and resin-
based composite-four or more surfaces or involving incisal angle (dental code D2335) for tooth #10 provided 
on February 7, 2022. 
 
You asked the Plan to pay for the limited oral evaluation and resin-based composite-four or more surfaces or 
involving incisal angle. You say that your dentist office told you the services should be covered by the Plan. 
The Plan denied your request. The Plan says these services are not covered by the Plan's 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 the 
limited oral evaluation (dental code D0140) and resin-based composite-four or more surfaces or involving 
incisal angle (dental code D2335) for tooth #10 provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth, partially bony (D7230) 
for tooth #17 and #32, deep sedation/general anesthesia, first 15 minutes (D9222) and deep sedation/general 
anesthesia, each subsequent 15-minute increment (D9223x2). 
 
You asked the Plan to pre-approve dental services. You say that you need to be sedated due to your abnormal 
mouth and jaw. You also say you have an infection of your wisdom tooth, and it needs to be pulled out or it 
will lead to other health issues. The Plan denied your request. The Plan says the requested procedure codes are 
not listed and therefore 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 
removal of an impacted tooth, partially bony (D7230) for tooth #17 and #32, deep sedation/general anesthesia, 
first 15 minutes (D9222) and deep sedation/general anesthesia, each subsequent 15-minute increment 
(D9223x2).