Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan of the 
lumbar spine and a specialist office visit provided from March 28, 2022, to March 29, 2022. 
 
You asked the Plan to waive the copayments for the CT scan and specialist visit. You say that you should not 
be responsible for these charges since the infection resulted from a procedure at the hospital. 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 $180 
copayment for each advanced imaging service, including CT scans. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each in-person specialist 
visit. You have been asked to pay $103.89 for the CT scan, which is less than the $180 copayment. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also 
been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for both services is 
$138.89. 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 a computed tomography (CT) scan of the 
lumbar spine and a specialist office visit provided from March 28, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 27, 
2021. You asked the Plan to pay for procedure code 99070. You say that this service was coded correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99070 is considered bundled and 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 procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a limited re-evaluation (D0170), osseous surgery (D4261), 
bone replacement graft (D7953), unspecified periodontal procedure (D4999), and root canal obstruction 
(D1010) provided from March 22, 2022, to March 29, 2022.  
 You asked the Plan to pay for a re-evaluation, osseous surgery, replacement graft, periodontal procedure, and 
root canal obstruction. You say that you disagree with the denial of dental services. The Plan denied your 
request. The Plan says a limited re-evaluation (D0170), osseous surgery (D4261), bone replacement graft 
(D7953), unspecified periodontal procedure (D4999), and root canal obstruction (D1010) 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for  a limited 
re-evaluation (D0170), osseous surgery (D4261), bone replacement graft (D7953), unspecified periodontal 
procedure (D4999), and root canal obstruction (D1010) provided from March 22, 2022, to March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-one to three teeth 
per quadrant (D4342) and the resin-based composite-one surface, anterior (D2330) provided on February 16, 
2022 and March 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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 the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the periodontal scaling and root planing-one to three teeth per quadrant (D4342) and the resin-based composite-
one surface, anterior (D2330) provided on February 16, 2022 and March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), periapical x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on May 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plan's cost-sharing amount when your services are received from 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for a periodic oral evaluation (D0120), 
prophylaxis (D1110), periapical x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a 
participating provider on March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would be covered. The 
Plan denied your request. The Plan says your maximum allowance benefit has already been 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your maximum benefit allowance amount of $250 for covered dental work has already been met and 
exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213) 
provided by a participating provider on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a desensitizing medicament (D9910) 
provided on December 14, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of 
a desensitizing medicament (D9910) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular dentures (D5120) provided on April 
19, 2022. 
 
You asked the Plan to pay for the dentures. You say that you were told that the insurance would cover 20% of 
the charges. The Plan denied your request. The Plan says complete mandibular dentures (D5120) 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 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 complete 
mandibular dentures (D5120) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 15, 2021, and a periapical x-ray (D0220) provided on March 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. The 
Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 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, certain limitations apply. The record 
shows your benefit for a comprehensive oral evaluation was exhausted on date of service October 7, 2021. The 
record also shows your benefit for a periapical x-ray was exhausted on date of service March 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 15, 2021, and a periapical x-ray (D0220) provided on March 17, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the facetectomy/foraminotomy for two of the spinal levels at issue. 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says that the records do not indicate that a facetectomy/foraminotomy (surgical procedures to 
remove pressure off the nerve (s) around the spine) is going to be performed to potentially remove a herniated 
(budging) disc or decompress (relieve pressure) the nerve root. The Plan states the records reflect that the 
enrollee has cervical myelopathy; therefore, the requested procedures with a diagnosis of M47.812 Spondylosis 
without myelopathy or radiculopathy cervical region, is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 surgery. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has metastatic cancer lesions to the cervical spine with cord compression. 
Laminectomy at multiple levels is required to decompress the cod. It should be approved. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve the facetectomy/foraminotomy for two of the spinal levels at issue.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a catheter placement procedure performed 
on March 15, 2022. 
 
You asked the Plan to waive the coinsurance for the catheter placement. You say that the test was necessary to 
be done prior to the procedure. You say that you feel you should not have to pay for the service. 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 10% 
coinsurance for each outpatient hospital visit.  
 
You have been asked to pay $357.05, which is 10% of the allowed amount for the catheter placement 
($3,570.47 allowed amount x 10% coinsurance = $357.05). The catheter placement falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a catheter placement procedure performed on 
March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
September 27, 2021. 
 
You asked the Plan to pay for the determination of refractive state. You say that you should not have to pay for 
this service. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions (D7210) provided by an out-of-network 
provider on March 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe this should be covered. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-
sharing amount when your services are received from 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for extractions (D7210) provided by an out-of-
network provider on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing rendered on March 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has unspecified rheumatoid 
arthritis. PrismRA testing does not have Food and Drug Administration (FDA) approval or clearance as a 
companion in vitro diagnostic. This test and the interpretive content have not been reviewed, cleared or 
approved by the FDA. The testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the PrismRA testing rendered on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel 
provided on December 17, 2021. 
 You asked the Plan to pay for the F1Heme panel. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this testing is unlikely to impact therapeutic decision making in the clinical 
management of the patient. 
 
The Plan follows Medicare rules. The rules say that coverage for molecular pathology testing is determined 
based on the guidelines listed 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 pay for the F1Heme panel. Our reviewer says that 
the requested testing is not medically reasonable and necessary. Our physician reviewer found only a small 
number of the genes included in this extensive panel are supported to guide treatment per the National 
Comprehensive Cancer Network (NCCN) guidelines. 
 
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 F1Heme panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival flap procedures (D4241) provided on July 8, 2021. 
 
You asked the Plan to pay for gingival flap procedures. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a gingival flap procedure (D4241) is not covered by your 
supplemental 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 gingival 
flap procedures (D4241) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided April 12, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you don't agree with the out-of-network cost-
sharing. The Plan denied your request. The Plan says your claim has been reprocessed as in-network, however 
the limited oral exam 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 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 
limited oral evaluation - problem focused (D0140) provided April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the enrollee has severe chronic obstructive 
pulmonary disease (COPD) with a recent hospitalization for acute hypercapnic respiratory failure. She may 
benefit from bi-level positive airway pressure (BiPAP) during sleep as an outpatient. A home ventilator is not 
reasonable or medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an upper partial denture (D5213) provided on February 
1, 2022. 
 
You asked the Plan to pay more for a partial denture. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your annual allowance for dental services has been 
exhausted. 
 
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 have a $2,000 
annual allowance for preventive and comprehensive dental services. The contract also says that the enrollee is 
responsible for any amount over and above the allowance amount. 
 
The record shows your annual allowance for dental services has been exhausted during the processing of this 
claim. You have been asked to pay the remaining balance of $2,040 for a partial denture. A partial denture falls 
within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for an upper partial denture 
(D5213) provided on February 1, 2022.