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

 
We decided that the Plan does not have to waive the coinsurance for an extraction (dental code D7210) and the 
oral surgery (dental code D7999) for tooth #30 provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for an extraction and the oral surgery. You say that you thought 
the services were covered. The Plan denied your request. The Plan says they overturned and reprocessed the 
claim with the proper coinsurance applied to each service. 
 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 in-network Extractions (Pulling Teeth)  Frequency/Limitations - Unlimited procedure codes 
and a 70% coinsurance for in-network Oral Surgery  Frequency/Limitations - 2 procedure codes per calendar 
year. The total allowed amount for the extraction was $204.52 with a coinsurance amount of $102.26 ($204.52 
total amount allowed x 50% coinsurance). The total amount allowed for the oral surgery was $77.09 with a 
coinsurance amount of $53.96 ($77.09 total amount allowed x 70% coinsurance). The total coinsurance amount 
for both services was $156.22. 
 
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. 
 
You have been asked to pay a $102.26 coinsurance for an extraction and a $53.96 coinsurance for the oral 
surgery. 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 an extraction (dental code D7210) and the oral 
surgery (dental code D7999) for tooth #30 provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary denture on December 21, 2021.

You asked the Plan to pay for a complete maxillary denture. You say that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the denied service isn't included in the member's benefit plan according to the member's EOC.

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 complete maxillary denture on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant maintenance procedure when prostheses are 
removed and reinserted, including cleansing of prostheses and abutments (D6080) provided on February 23, 2022. 
 
You asked the Plan to pay for the implant maintenance procedure. You say that your lower implants must be 
maintained regularly every three months so they should not have been denied. The Plan denied your request. 
The Plan says the implant maintenance procedure is not covered under your supplemental 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. 
 
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 
implant maintenance procedure when prostheses are removed and reinserted, including cleansing of prostheses 
and abutments (D6080) provided on February 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (88377, 88368, 88291, 88349, 88344, and 
88342) provided on May 13, 2021. 
 
You asked the Plan to pay for codes 88377, 88368, 88291, 88349, and 88342. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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. 
 
The enrollee was referred for codes 88377, 88368, 88291, 88349, and 88342 by a contract provider. The file 
does not show that the plan provided notice that codes 88377, 88368, 88291, 88349, and 88342 would not be 
covered. Under Medicare rules, this means codes 88377, 88368, 88291, 88349, and 88342 are considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services (88377, 88368, 
88291, 88349, 88344, and 88342) provided on May 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 the panoramic radiographic image (D0330) provided on 
March 3, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were unaware it was only covered once 
every 36 months, and you were only one month away from getting it approved. The Plan denied your request. 
The Plan says the service was provided before 36 months had passed from the previous service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers panoramic x-
rays once every 36 months when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral 
radiographic images (D0210) provided on March 14, 2022. 
 
You asked the Plan to pay for comprehensive oral evaluation and intraoral radiographic images. You say that 
there are few dentists in your area that takes this plan, so you are limited on your choices, as well as not being 
permitted to continue to use your personal dentist. The Plan denied your request. The Plan says there is no 
coverage for when services are rendered 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, out-of-network dental services are not 
a covered benefit. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation 
(D0150) and intraoral radiographic images (D0210) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the complete intraoral series (D0210), comprehensive 
evaluation (D0150), scaling/planning (D4341), and scaling/planing (D4342) provided on October 12, 2021. 
The scaling/planing (D4342) provided on October 13, 2021. The periodontal maintenance (D4910) provided on 
January 20, 2022, and pay for the topical fluoride (D1206) provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for the intraoral series, evaluation, scaling/planing, and pariodontal 
maintenance, and pay for the topical fluoride. You say that you were not able to see the breakdown of the 
charges on the Plan's website. The Plan denied your request. The Plan says that the copayments were charged 
correctly, and D1206 is not a covered service. 
 
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 forwarded to us a complete 2021 and 2022 Evidence of 
Coverage (EOC) to support their denial of these dental services. Therefore, we decided that the Plan has to 
waive the copayment for the complete intraoral series (D0210), comprehensive evaluation (D0150), 
scaling/planning (D4341), and scaling/planing (D4342) provided on October 12, 2021. The scaling/planing 
(D4342) provided on October 13, 2021. The periodontal maintenance (D4910) provided on January 20, 2022, 
and for the Plan to pay for the topical fluoride (D1206) provided on January 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing provided on 
September 24, 2021, billed with codes 81238, 81220, 81226, 81225, 81335, 81227, 81230, 81355, 81241, 
81291 and 81240. 
 
You asked the Plan to pay for the comprehensive pharmacogenomic testing. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says this should have been billed with a single panel 
code. Therefore, only 11 of the 16 line items will be paid. 
 The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. This is an NGS panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the comprehensive 
pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
comprehensive pharmacogenomic testing provided on September 24, 2021, billed with codes 81238, 81220, 
81226, 81225, 81335, 81227, 81230, 81355, 81241, 81291 and 81240.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic manipulative treatment provided on October 4, 2021. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that this is a chiropractor, and the 
service is manual manipulation. You say that this type of provider is allowed to perform this procedure. The 
Plan denied your request. The Plan says that the acupuncture has been overturned and the chiropractic 
manipulative treatment provided on October 8, 2021, and October 11, 2021, has been overturned. The 
chiropractic manipulative treatment provided on October 4, 2021, remains denied as a duplicate service that has 
already been paid. 
 
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 says the chiropractic manipulative treatment provided on October 4, 
2021, is a duplicate service that was already paid on another claim. The Plan did not submit documentation 
supporting that this service was already paid on another claim. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for chiropractic manipulative treatment provided on 
October 4, 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: Favorable

 
We decided that the Plan has to pre-approve abutment supported by a crown on tooth #18 (D6059) and custom 
abutment on tooth #18 (D6057). 
 
You asked the Plan to pre-approve abutment and supported crown. You say that you believed these were 
covered services. The Plan denied your request. The Plan says that these services are not covered by your 
Plan's benefits. 
 
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 did not provide the correct Evidence of Coverage (EOC). Without the 
EOC we are unable to determine if the dental services requested are excluded from coverage. Therefore, we 
decided that the Plan has to pre-approve abutment supported by a crown on tooth #18 (D6059) and custom 
abutment on tooth #18 (D6057).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan. 
 
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 LTACH services have not been met.  
  
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 test purchased on January 18, 2022. 
 
You asked the Plan to pay for the at home COVID-19 test. You say that the government had announced that 
each person can pay out of pocket for up to four testing kits and will be reimbursed by their insurance. The 
Plan denied your request. The Plan says this was not a covered benefit at the time you purchased this test. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter (OTC) 
items and the at home COVID-19 test is an OTC item. However, the Plan offers a supplemental benefit for 
over-the-counter home COVID-19 tests purchased after February 1, 2022. These tests were purchased on 
January 18, 2022, which is before this benefit went into effect. Therefore, we decided that the Plan does not 
have to pay for the at home COVID-19 test purchased on January 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests (U0002) and 
sales tax (S9999) purchased on January 10, 2022, and January 18, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that on the television it said if you bought at home 
COVID-19 tests you would be reimbursed by your insurance company. The Plan denied your request. The Plan 
says Medicare will not provide payment for over-the-counter COVID-19 tests obtained prior to April 4, 2022. 
The Plan also says that Medicare does not reimburse separately for sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan. Medicare rules also say sales taxes are included in the calculation of the Medicare fee schedule, and 
a separate payment is not made for sales tax. 
 
 We looked at the file and Medicare rules. Over-the-counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests (U0002) and sales tax (S9999) 
purchased on January 10, 2022, and January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation and intraoral x-ray (D0140, D0210) 
provided on March 10, 2022. 
 
You asked the Plan to pay for the oral evaluation and intraoral x-ray. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 oral 
evaluation and intraoral x-ray (D0140, D0210) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental osseous surgery (D4260) provided on August 17, 2021. 
 
You asked the Plan to pay for the dental osseous surgery. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 dental 
osseous surgery (D4260) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on November 19, 2021. 
 
You asked the Plan to pay for the office visit (99203). You say that the claim should be reconsidered for 
payment. The Plan denied your request. The Plan says a new patient evaluation and management code will only 
be reimbursed when the elements of the new patient definition have been met. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter.  We find that CPT code 99203 is not supported in the medical record. Specifically, the enrollee received 
services from the same physician group with physicians that have the same specialty prior to this visit. This 
means that the enrollee would not be considered a new patient. Based on this information, we decided that 
Medicare rules for coverage of the new patient office visit (99203) have not been met. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) provided on November 19, 2021.