Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hemoglobin test (83036) provided on October 6, 2021.
You asked the Plan to pay for the hemoglobin test. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says tests with no relations for the health of the patient are not a covered benefit.
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 test at issue in this appeal, the hemoglobin test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hemoglobin test (83036) provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee (L5828 L5845 L5848 L5856). 
 
You asked the Plan to pre-approve a K3 microprocessor knee. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the records do not support the 
need for a microprocessor knee instead of a mechanical knee. 
 
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 a K3 microprocessor knee. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the documentation indicates that the enrollee has been using a 
walker and a wheelchair but is expecting to be a community ambulator with the proper prosthesis. The health 
plan has authorized a K3 level prosthesis. It is unclear why the electronic/microprocessor knee has been 
requested. The documentation does not indicate why a mechanical knee cannot be used. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 microprocessor knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K3 microprocessor knee (L5828 L5845 L5848 L5856).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry (83789) provided October 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the billed services were not 
supported. 
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 83789 is mass spectrometry and tandem mass 
spectrometry (MS, MS/MS), analyte not elsewhere specified. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
reimbursed when billed for specimen validity testing on specimens used for drug testing. The Plan made 
multiple attempts to obtain additional information from the provider without success. 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 mass spectrometry (83789) provided October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and periodontal scaling and 
root planing - four or more teeth per quadrant (D4341). 
 
You asked the Plan to pre-approve an upper partial denture and periodontal scaling and root planing. You say 
that you need these services, and you have not had any dentures done in the past 5 years. The Plan denied your 
request. The Plan says you have exceeded the frequency limit for these services. 
 
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 an upper 
partial denture once every 5 calendar years and periodontal scaling and root planing once per quadrant every 3 
calendar years.   
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling 
and root planing was previously covered for the lower left and right quadrants on November 4, 2020. The Plan 
also provided documentation showing that an upper partial denture was previously covered on April 12, 2018. 
Based on this information, we decided that the Plan's frequency limits for coverage of an upper partial denture 
and periodontal scaling and root planing would be exceeded with the requested services. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5213) and periodontal scaling and root planing 
- four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you cannot afford this out-of-pocket. The Plan 
denied your request. The Plan says the enrollee's $1,000 allowance for covered comprehensive dental services 
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 up to a $1,000 
allowance for covered comprehensive dental services. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the $1,000 dental allowance has 
already been exhausted. Based on this information, we decided that the Plan's rules for coverage of dental 
services have already been met and exhausted. Therefore, we decided that the Plan does not have to pre-
approve dental services to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the oral hygiene instruction (D1330 x 2) 
provided from October 13, 2021, to October 29, 2021. 
 
You asked the Plan to pay the in network rate for the oral hygiene instruction. You say that the provider 
assured that they were in network prior to the services being rendered. You say that you were not aware that the 
provider was out of network until after you received the services. You also say that The Plan denied your 
request. The Plan says oral hygiene instruction is not listed as a covered service. 
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 oral hygiene instruction is not 
among those covered under this benefit regardless of the provider's network status. Therefore, we decided that 
the Plan does not have to pay the in network rate for the oral hygiene instruction (D1330 x 2) provided from 
October 13, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), bitewing x-ray (D0270), and simple extraction (D7140) provided on 
February 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 
bitewing x-ray, and simple extraction. You say that a Plan representative told you this provider was 
participating. You also say that the dental office advised the same thing. The Plan denied your request. The 
Plan says services are only covered by the Plan for in-network dentists. The Plan also says that the records do 
not show that your dentist is in the Plan's provider network. 
 
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 problem 
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray (D0270), and 
simple extraction (D7140) provided on February 15, 2022 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 two surgical placements of implant bodies: endosteal 
implants (D6010 x2) provided on July 9, 2021. 
 
You asked the Plan to pay for the endosteal implants. You say that this dental work was the result of having 
been treated with chemotherapy twice. The Plan denied your request. The Plan says the dental plan does not 
offer coverage for dental implants. 
 
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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crown (high 
noble metal) (D6059), custom fabricated abutment  includes placement (D6057), and prefabricated abutment 
 includes modification and placement (D6056) provided November 9, 2021. 
 
You asked the Plan to pay for the abutments. You say that these services are necessary and are related to dental 
degradation related to chemotherapy received prior to your retirement. The Plan denied your request. The Plan 
says these services are 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 
abutment supported porcelain fused to metal crown (high noble metal) (D6059), custom fabricated abutment  
includes placement (D6057), and prefabricated abutment  includes modification and placement (D6056) 
provided November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), and bone 
replacement graft for ridge preservation (D7953), or pay more for the comprehensive oral evaluation (D0150) 
provided on August 18, 2021 by an out-of-network (OON) provider. 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft, and to pay more for 
the comprehensive oral evaluation. You say that you would like to appeal these services. The Plan denied your 
request. The Plan says the guided tissue regeneration and bone replacement graft are not covered expenses 
under your dental plan. The Plan also says that these services were performed by a non-participating provider, 
and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider 
bills you for the services. 
 
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 guided tissue regeneration (D4266) 
and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The 
contract says that you are responsible for a 50% coinsurance for the comprehensive oral evaluation (D0150), 
plus the difference between the billed amount and allowed amount because this service was received OON. 
Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266), and bone 
replacement graft for ridge preservation (D7953), or pay more for the comprehensive oral evaluation (D0150) 
provided on August 18, 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 two localized deliveries of antimicrobial agents (D4381 
x2) and periodontal maintenance (D4910) provided on January 31, 2022. 
 
You asked the Plan to pay for the localized deliveries of antimicrobial agents and periodontal maintenance. 
You say that you were misinformed about the procedure and benefits. You also say that you thought by going 
to a better dentist that these services would be covered. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that you did not call in prior to 
services being rendered to verify benefits or 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
localized deliveries of antimicrobial agents (D4381 x2) and periodontal maintenance (D4910) provided on 
January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperthermia treatment (77600) provided from August 28, 
2021, to September 21, 2021.  
You asked the Plan to pay for hyperthermia treatment. You say that this should be covered. The Plan denied 
your request. The Plan says this is 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, we have confirmed that code 77600 
is a column II code to column I code 77605, which was previously billed and paid. Modifiers are not allowed 
on this pair and will not bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for hyperthermia treatment (77600) provided 
from August 28, 2021, to September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lung cancer panel testing services provided on March 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that genetic testing is medically necessary for 
cancer patients. The Plan denied your request. The Plan says one code must be submitted for the panel. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. If a single procedure is performed, only one code with one unit of service 
may be reported for the procedure. 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 lung 
cancer panel testing services provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that you were advised by the dental representative 
that all was covered. You say that you do not have money to have an implant. You also say that you need all 
the help you can get. The Plan denied your request. The Plan says partial upper denture is not listed as a 
covered dental item. 
 
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 partial upper denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the pontic (D6240) for tooth # 10 and retainer crowns (D6750) for 
tooth #'s 9 and 11 provided on February 10, 2022. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that you would like to appeal these 
services because you are allergic to the metal on partial dentures. The Plan denied your request. The Plan says 
that the documentation fails to indicate any specific needs or conditions that preclude the use of a removable 
prosthesis. 
 
The Medicare rules say that the health plan must provide you with a clear and accurate description of the 
Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 
 
The record shows that you received a pontic (D6240) for tooth # 10 and retainer crowns (D6750) for tooth #'s 9 
and 11. The 2022 Evidence of Coverage lists these services as covered benefits. The contract does not provide 
any limitations or exclusions to these services, nor does it state that prior authorization is required. You 
reasonably believed these services would be covered because fixed partial dentures are listed as a covered 
benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the pontic and retainer crowns have been met. Therefore, we decided that the Plan has to pay for 
the pontic (D6240) for tooth # 10 and retainer crowns (D6750) for tooth #'s 9 and 11 provided on February 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) provided on November 24, 2021. 
 
You asked the Plan to pay for sales tax. You say that you would like reimbursement for the money you spent 
for the system. The Plan denied your request. The Plan says sales tax is non-covered as it is not a Medicare 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
We find that CPT code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
(S9999) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99213, 99214) and 
ophthalmic diagnostic imaging (92134) provided on September 11, 2021, to November 1, 2021. 
 
You asked the Plan to waive the copayment for office visits and diagnostic imaging. You say that you disagree 
with the charges.  The Plan denied your request. The Plan says the copayments you are being charged are 
correct. 
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 per ophthalmology visit and a $25 copayment for urgent care visits.  
 
You have been asked to pay a $35 copayment for each office visit and urgent care visits. The records show that 
you had an urgent care visit on September 11, 2021. The records also show that you had a diagnostic imaging 
visit with your ophthalmologist on September 15, 2021, September 20, 2021, and November 1, 2021. The EOC 
confirms that you pay a $35 copayment for each visit with your ophthalmologist and a $25 copayment for an 
urgent care visit. Your total cost share is $130 ($35 + $35 + $35 + $25 = $130). 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 an office visit (99213, 99214) and ophthalmic diagnostic imaging (92134) provided 
on September 11, 2021, to November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
20, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says the enrollee was not enrolled in the 
supplemental dental plan at the time of service. The Plan also says that this service is 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on January 20, 2022.