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

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2022, billed with 
codes 81225, 81226, 81401, 81406, 81479, 81220, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81283, 
81291, 81306, 81328, 81335, 81350, 81355, 81381, and 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary to 
make treatment decisions for the enrollee. The Plan denied your request. The Plan says this testing should be 
reported with a single panel code. 
 
The Plan must follow Medicare rules. The 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 was 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 genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 22, 2022, billed with codes 81225, 81226, 81401, 81406, 81479, 81220, 81227, 81230, 81231, 81232, 
81240, 81241, 81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, 81381, and 81400.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF for the enrollee. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210), 2D oral/facial photographic 
images (D0350 x 4), and a panoramic x-ray (D0330) provided on May 3, 2022. 
 
You asked the Plan to pay for the x-rays and images. You say that these services should be covered. The Plan 
denied your request. The Plan says an intraoral x-ray (D0210), 2D oral/facial photographic images (D0350), 
and a panoramic x-ray (D0330) 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 an 
intraoral x-ray (D0210), 2D oral/facial photographic images (D0350 x 4), and a panoramic x-ray (D0330) 
provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewing x-rays (D0274), panoramic x-ray 
(D0330), and prophylaxis (D1110) provided on February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the bitewing x-rays, panoramic x-ray, and prophylaxis. You say that you 
were not told that you were getting two sets of x-rays. You also say that you thought you were only getting 
bitewings and a cleaning. The Plan denied your request. The Plan says this claim was processed according to 
the terms of your 2022 Evidence of Coverage. 
 
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, you are responsible for a $10 
copayment for each preventive service, plus the difference between the billed amount and allowed amount 
because these services were received OON. Therefore, we decided that the Plan does not have to pay more for 
the bitewing x-rays (D0274), panoramic x-ray (D0330), and prophylaxis (D1110) provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on May 4, 2022. 
 
You asked the Plan to pay more for the dental services. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans 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 Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
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 prophylaxis (D1110) provided on May 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions (D7210, D7140) provided on May 12, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the procedure would be 
covered at 50% of the cost. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The Plan also says that enrollees must pay 50% coinsurance for extractions. 
 
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 50% coinsurance for each extraction. You have also been asked to pay the 
difference between the out-of-network providers charges and the Plans payment.  
 
Code Allowed Amount 50% Coinsurance Total Responsibility 
D7210 $108 $54 $230 
D7210 $108 $54 $230 
D7210 $108 $54 $230 
D7140 $56 $28 $156 
D7140 $56 $28 $156 
Total   $1,002 
 
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, D7140) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve restorative procedures (D2999) for tooth #'s 28 and 29, 
applications of desensitizing resin (D9911) for tooth #'s 28 and 29, and indirect pulp caps (D3120) for tooth #'s 
28 and 29. 
 
You asked the Plan to pre-approve the restorative procedures, applications of desensitizing resin, and indirect 
pulp caps. You say that you need your bridgework to be redone. The Plan denied your request. The Plan says 
these services are purely dental in nature, and cannot be covered under your medical plan. The Plan also says 
that you are over the age limit for the indirect pulp caps to be covered. 
 
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 unspecified restorative procedures 
and applications of desensitizing resin are not among those covered under this benefit. The contract says that 
indirect pulp cap (D3120) is only covered for enrollees between the ages of 0 and 20 years old. The record 
shows that you exceed this age limit. Therefore, we decided that the Plan does not have to pre-approve 
restorative procedures (D2999) for tooth #'s 28 and 29, applications of desensitizing resin (D9911) for tooth #'s 
28 and 29, and indirect pulp caps (D3120) for tooth #'s 28 and 29.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiomyopathy genetic testing panel provided on July 
16, 2021, billed with codes 81404, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The 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 was 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the cardiomyopathy genetic 
testing panel provided on July 16, 2021, billed with codes 81404, 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root amputation (D3450) provided by a network provider 
on March 26, 2022. 
 
You asked the Plan to pay for the root amputation (D3450). You say that you were referred to this dentist in 
order to have the root and small piece of tooth to be removed. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 root 
amputation (D3450) provided by a network provider on March 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) provided by a 
participating provider. 
 
You asked the Plan to pre-approve periodontal maintenance. You say that you would like the Plan to approve 
this dental service. The Plan denied your request. The Plan says the requested dental work is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal maintenance (D4910) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that D2740 is medically necessary. The Plan denied your 
request. The Plan says D2740 has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that a 
crown is not medically necessary. Our physician reviewer found Tooth #7 does not exhibit significant 
structural breakdown such that a full coverage crown restoration would be needed. 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #7 provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953), guided tissue regeneration 
(D4267), and therapeutic parenteral drugs (D9612) provided on May 20, 2022. 
 
You asked the Plan to pay for a graft, tissue regeneration, and parenteral drugs. You say that the provider 
should be considered out-of-network. The Plan denied your request. The Plan says a bone replacement graft 
(D7953), guided tissue regeneration (D4267), and therapeutic parenteral drugs (D9612) 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 bone 
replacement graft (D7953), guided tissue regeneration (D4267), and therapeutic parenteral drugs (D9612) 
provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse an additional amount for the comprehensive oral evaluation (D0150) 
and root canal (D3330) provided on May 16, 2022. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you should be 
reimbursed an additional $180. You say that there were no endodontists that could tend to you in the hospital. 
You also say that you had no choice but to go out of network. The Plan denied your request. The Plan says that 
the claim processed correctly. 
 
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. Specifically, the file does not show what the allowed amounts for the services 
are. The file does not show what amount was reimbursed to you and why. Without this information, we cannot 
determine if the Plan reimbursed the correct amount. Therefore, we decided that the Plan has to reimburse an 
additional amount for the comprehensive oral evaluation (D0150) and root canal (D3330) provided on May 16, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), a complete 
mandibular denture (D5120), and unspecified removable prosthodontic procedure reports (D5899) provided on 
March 29, 2022. 
 
You asked the Plan to pay for dentures and procedure reports. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says a complete maxillary denture (D5110), a complete 
mandibular denture (D5120), and unspecified removable prosthodontic procedure reports (D5899) 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 complete maxillary denture (D5110), a complete mandibular denture (D5120), and unspecified removable 
prosthodontic procedure reports (D5899) provided on March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat colonoscopy after five years. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the pathology report and family history do not put the enrollee at high risk. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records do not provide any evidence that you are considered high risk for colorectal cancer. 
Colonoscopy at the 5-year interval under review in follow-up to hyperplastic polyps is neither medically 
appropriate nor 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat colonoscopy after five years.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) and medicaments 
dispensed in the office (D9630) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an adjunctive pre-diagnostic test (D0431) and medicaments 
dispensed in the office (D9630) are not covered by your 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 an 
adjunctive pre-diagnostic test (D0431) and medicaments dispensed in the office (D9630) provided on February 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported crown (D6059) provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that this dental work is medically necessary. The Plan denied your request. The Plan says the requested dental 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a 
custom fabricated abutment (D6057) and an abutment supported crown (D6059) provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 the requested item or service was exhausted on date of service September 9, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2740) and core buildup (D2950) for tooth #5 provided on 
April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that there was decay in the tooth, and you were told 
it would be covered. The Plan denied your request. The Plan says that the records did not show a cavity or 
fracture affecting chewing or exposing the tooth underneath; therefore, the payment for the dental services was 
denied. 
 
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 the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the documentation provided meets the criteria for coverage for a core buildup (D2950) and crown restoration 
(D2740) for tooth #5. Our physician reviewer found that included in the documentation was a narrative 
indicating that tooth #5 had a three-surface alloy restoration with recurrent caries and fracture lines. Upon 
removal of the old restoration a buildup was required to obtain support and retention for a crown restoration. A 
crown restoration was medically reasonable and necessary to provide adequate support and masticatory 
function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pay for a crown (D2740) and core buildup (D2950) for tooth #5 provided on April 29, 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.