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

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 
21, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you are covered for dental cleanings 
twice per year. The Plan denied your request. The Plan says this procedure exceeds the frequency limitations 
under your plan. 
 
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, periodontal cleaning is covered once 
every 6 months. The record shows that you received a periodontal maintenance (D4910) on November 18, 
2021 and your periodontal maintenance (D4910) benefit had been exhausted. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 81479 provided on April 7, 2021.  
You asked the Plan to pay for the laboratory services. You say that the medical records will prove that the 
services billed are medically necessary. Kindly review the medical records and process the claim towards 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for laboratory services coded as 81479 provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the chiropractic office visit. You say that the Plan's portal website listed the 
provider as in-network. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the chiropractic office visit. We found no exception that would require the Plan to 
pre-approve the chiropractic office visit. Therefore, we decided that the Plan does not have to pre-approve the 
chiropractic office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compressor and the segmental pneumatic appliance. You say 
that the equipment is medically necessary. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the pneumatic compressor and the segmental pneumatic appliance. We found no 
exception that would require the Plan to pre-approve the pneumatic compressor and the segmental pneumatic 
appliance. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compressor and 
segmental pneumatic appliance to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #13 (D2950), and the third crown 
(D2740) provided on February 14, 2022. 
 
You asked the Plan to pay for core build up and crowns. You say that you were unaware there was a limitation 
on the number of covered crowns per year. The Plan denied your request. The Plan says core build up (D2950) 
is not covered by your dental benefits. The Plan also says that a crown (D2740) is a covered service; however, 
your benefit for two crowns per year has 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. The Plan covers two crowns 
(D2740) per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core build up (D2950) is not among 
those covered under this benefit. We looked at this case file, the Plan's rules, and Medicare rules. The Plan 
approved coverage for two crowns on the same date of service, February 14, 2021; therefore, the benefit for 
crowns has been exhausted. Therefore, we decided that the Plan does not have to pay for core build up on tooth 
#13 (D2950), and the third crown (D2740) provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for zoster (shingles) vaccine (90750) provided January 20, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that you received a bill of $364 for a shingles shot. 
You were told you would be paying $70. You do not understand why it had not been submitted to Medicare. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for zoster (shingles) vaccine (90750) 
provided January 20, 2022.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
limited oral evaluation (D0140), the extraction of an erupted tooth requiring removal of bone and/or sectioning 
of tooth) (D7210), and the oral hygiene instructions (D1330) provided on November 8, 2021 and November 15, 2021. 
 
You asked the Plan to pay for these 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 services provided in this case are 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 Plan's coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral-periapical first radiographic image (D0220), limited oral evaluation (D0140), the extraction of an 
erupted tooth requiring removal of bone and/or sectioning of tooth) (D7210), and the oral hygiene instructions 
(D1330) provided on November 8, 2021 and November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental injections provided on December 17, 2021 and 
December 21, 2021. 
 
You asked the Plan to pay for dental injections. You say that this was a medical reimbursement, not a dental 
reimbursement. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, 
because these drugs are not covered by your Medicare Part B benefits and may be covered by your Medicare 
Part D prescription drug benefits instead. 
 
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 dental 
injections provided on December 17, 2021 and December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin restoration on tooth #13 (D2951) provided on February 
21, 2022. 
 
You asked the Plan to pay for pin restoration. You say that your tooth broke into pieces, and you did not want it 
pulled so you had the dentist put a pin in the tooth. The Plan denied your request. The Plan says pin restoration 
(D2951) is 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 pin 
restoration on tooth #13 (D2951) provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on November 22, 2021. 
 You asked the Plan to pay for the services provided. You say that the device is used in facility for the 
prevention of thrombotic events. The Plan denied your request. The Plan says the device is not covered to 
prevent deep vein thrombosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device and related services provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure (41899). 
 
You asked the Plan to pre-approve the dental surgery procedure. You say that the enrollee is in need of a full 
mouth extraction with placement of dentures the same day. You also say that the enrollee is in pain and has 
severe decay of teeth. The Plan denied your request. The Plan says the requested dental services are not 
covered under the enrollee's health plan. The Plan also says that it was confirmed that the enrollee does not 
have any separate dental rider with the Plan. 
 
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 pre-approve a dental surgery procedure (41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057 x 3) and abutment supported 
crowns (D6058 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you already paid to have services started 
last year. You say that some of the services were approved under another authorization. You also say that these 
services are necessary to prevent infection. The Plan denied your request. The Plan says custom abutments and 
abutment supported crowns are not listed as covered dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested custom abutments and 
abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve custom abutments (D6057 x 3) and abutment supported crowns (D6058 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on March 1, 2022. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say that the services 
should be covered as you disagree with the charges. 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 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 core 
buildup, including any pins when required (D2950) provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this equipment is medically 
necessary for treating the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage of this device have not been satisfied. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory pathogen panel testing provided on June 8, 2021. 
 
You asked the Plan to pay for lab test. You say that your lab performed all of the tests ordered by the referring 
physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
the documentation shows that this testing included more than 5 targets which is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panels with greater than 5 respiratory 
pathogens are not considered medically reasonable and necessary.  
 
We looked at the file and Medicare rules. The record shows that this panel testing included more than 5 
respiratory pathogen targets. Based on this information, we decided that Medicare rules for coverage of lab test 
have not been met. Therefore, we decided that the Plan does not have to pay for respiratory pathogen panel 
testing provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not a Medicare benefit for the diagnosis listed. 
 
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 file shows that fluorescence in situ hybridization (FISH) testing was provided to the enrollee. In this case, 
there are insufficient medical records from the enrollees treating physician. Testing is not considered 
necessary merely on the basis of a particular diagnosis. Medicare does not cover the testing at issue for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genesight Psychotropic testing panel provided on July 28, 
2021. 
 
You asked the Plan to pay for Genesight Psychotropic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing service is not 
covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Therefore, we 
decided that the Plan does not have to pay for Genesight Psychotropic testing panel provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation for gel injections to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation for gel injections. You say that you need the gel injection 
for your knees, but the injection is not provided in-network. The Plan denied your request. The Plan says the 
provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the consultation for gel injections. We found no exception that would require the 
Plan to pre-approve the consultation for gel injections. Therefore, we decided that the Plan does not have to 
pre-approve the consultation for gel injections to be provided 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 comprehensive periodontal evaluation (D0180), two 
dimensional (2D) oral/facial photographic image (D0350), and preventive procedure (D1999) provided on 
October 22, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation, 2D oral/facial photographic image, 
and preventive procedure. You say that you would like to appeal these services. The Plan denied your request. 
The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180), two dimensional (2D) oral/facial photographic image (D0350), 
and preventive procedure (D1999) provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) and a retainer crown (D6740), provided by 
an out-of-network provider. 
 
You asked the Plan to pay for a pontic and a retainer crown. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the rendered services are not 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 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 pontic 
(D6245) and a retainer crown (D6740), provided by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the Cologuard test provided on February 1, 2022. 
 
You asked the Plan to pay for the Cologuard test. 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. 
 
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. 
 
You were referred for the Cologuard test by a contract provider. The file does not show that the Plan provided 
notice that the Cologuard test would not be covered. Under Medicare rules, this means the Cologuard test is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Cologuard test 
provided on February 1, 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.