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

 
We decided that the Plan does not have to pay for a diagnostic consultation service provided by dentist or 
physician other than the practitioner providing treatment (D9310), pulp vitality tests (D0460) and a cone beam 
computed tomography (CT scan) capture and interpretation with limited field of view- less than one whole jaw 
(D0364) provided on February 16, 2022. 
 
You asked the Plan to pay for a diagnostic consultation service provided by dentist or physician other than the 
practitioner providing treatment, pulp vitality tests and a cone beam computed tomography (CT scan) capture 
and interpretation with limited field of view- less than one whole jaw. You say that you were told it appeared 
you might have a cavity below the gum and that you had three choices, and your choice was a root canal to 
save the tooth. You also said that you asked for a referral for a provider you found closer to your home, and the 
provider at that clinic could find no reason to do a root canal. You also say that you feel she did the additional x-rays and services to make sure she was not missing something. The Plan denied your request. The Plan says 
the services are not covered under the member's contract under any normal circumstances. The Plan also says 
that per the member's 2022 EOC, the Plan has limited dental benefits and these services are excluded. 
 
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. This benefit does not include a 
diagnostic consultation service provided by dentist or physician other than the practitioner providing treatment 
(D9310), pulp vitality tests (D0460) and a cone beam computed tomography (CT scan) capture and 
interpretation with limited field of view- less than one whole jaw (D0364). 
 
We looked at the file, the Plans rules, and Medicares rules. A diagnostic consultation service provided by 
dentist or physician other than the practitioner providing treatment (D9310), pulp vitality tests (D0460) and a 
cone beam computed tomography (CT scan) capture and interpretation with limited field of view- less than one 
whole jaw (D0364) are not among those covered in this benefit. Therefore, we decided that the Plan does not 
have to pay for a diagnostic consultation service provided by dentist or physician other than the practitioner 
providing treatment (D9310), pulp vitality tests (D0460) and a cone beam computed tomography (CT scan) 
capture and interpretation with limited field of view- less than one whole jaw (D0364) provided on February 
16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapist services provided from 
May 9, 2022, through July 7, 2022. 
 
You asked the Plan to pre-approve home health physical therapist services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says there is no documentation which meets the 
criteria for continued home health services per Medicare coverage guidelines. The member could show 
increased improvement with outpatient therapy.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapist services. 
Our reviewer says that home health physical therapist services are not medically necessary. Our physician 
reviewer found that the documentation doesnt support that you require additional skilled rehabilitation services 
to provide treatment that is medically necessary. You do not require additional rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. There has not been a decline in your 
function and you should be independent with a home exercise program. The requested home health services are 
not 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 home health physical therapist services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapist services provided from 
May 9, 2022, through July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on August 12, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed correctly 
based on Medicare coding regulations. 
 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 Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on January 13, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you called on January 12, 2022 to ask if there was 
coverage, and were told the Plan would cover all but $699 of the cost. You also say that if you had known you 
only had coverage through the Plan's approved hearing aid vendor and brand, you would not have purchased 
the hearing aids. The Plan denied your request. The Plan says your hearing aid benefit is limited to the Plans 
approved hearing aid brand. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are the Plan's approved hearing aid brand, and are rendered by a 
network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) provided on January 13, 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 oral surgery in the upper right quadrant (D7320) provided on 
February 14, 2022. 
 
You asked the Plan to pay for oral surgery. You say that you requested the Plan increase your maximum annual 
allowance considering you are so close to finishing treatment. The Plan denied your request. The Plan says you 
have exceeded your $1,000 allowance for non-Medicare covered comprehensive 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. 
 
The record shows you have exceeded your $1,000 allowance during the processing of this claim. Therefore, we 
decided that the Plan does not have to pay for oral surgery in the upper right quadrant (D7320) provided on 
February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral periapical radiograph (D0230) provided 
on January 19, 2022. 
 
You asked the Plan to pay for additional intraoral periapical radiograph (D0230). You say that the x-ray should 
be covered. The Plan denied your request. The Plan says this benefit 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 Plans coverage rules apply in this case. This benefit includes intraoral 
x-rays (inside the mouth)-frequency/limitations-one procedure code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested additional intraoral 
periapical radiograph (D0230) was not covered under this benefit. On January 19, 2022, it shows the plan paid 
for intraoral periapical first radiographic image (D0220). The Plan will only pay for one of these services per 
calendar year. Therefore, we decided that the Plan does not have to pay for additional intraoral periapical 
radiograph (D0230) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on February 2, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says these services are not listed as covered benefits in the members 
EOC. 
 
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 
services on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on November 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
care. 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the gene 
panel provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that due to the lack of staff it was not 
possible to obtain an authorization prior to the service that was rendered to the enrollee. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on February 
21, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional coverage for an Alveoloplasty, each quadrant 
(41874) and a dental surgery procedure (41899). 
 
You asked the Plan to pre-approve additional coverage above the supplemental benefit limit. You say that you 
are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request 
does not meet Medicare criteria for additional coverage. 
 
The rules say that hospital inpatient services which are necessary because of the patient's underlying medical 
condition and clinical status or the severity of a noncovered dental procedure, are covered. When the hospital 
services are covered, all ancillary services such as x-rays, administration of anesthesia, use of the operating 
room, etc., are covered. 
 
The services you are asking the Plan to pre-approve additional coverage for involve the care, treatment, filling, 
removal or replacement of your teeth or the structures directly supporting your teeth. The requested dental 
services are not covered or paid for by Medicare. Additionally, your request involves an outpatient admission 
for these services, which does not meet Medicare criteria for coverage of dental care. Only medically necessary 
inpatient care for dental services would be covered by Medicare. Please note, the Plan has approved coverage 
for these services up to $1,000 for the supplemental dental benefit allowance. Therefore, we decided that the 
Plan does not have to pre-approve additional coverage for an Alveoloplasty, each quadrant (41874) and a 
dental surgery procedure (41899).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID tests you purchased on December 9, 
2021. 
 
You asked the Plan to pay for the at-home tests. The Plan denied your request. The Plan says the tests were 
purchased before the benefit was in effect. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
tests are an OTC item. Therefore, we decided that the Plan does not have to pay for the at-home COVID tests 
you purchased on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on February 2, 2022.  
You asked the Plan to pay for the refraction. You say that for the past 60 years you had a yearly eye exam that 
was always paid for. You say that you were informed the claim denied in error and an adjustment would be 
processed. The Plan denied your request. The Plan says the office visit, fundus photography and visual field 
examination were paid. The Plan also says the refraction remains denied as a non-covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The refraction is considered routine vision services or eyewear. Therefore, we decided that the Plan does not 
have to pay for the refraction provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic 
radiographic imaging (D0330), and risk assessment and documentation (D0601), provided by a participating 
provider on March 29, 2022, to April 13, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation, panoramic radiographic imaging, and risk 
assessment and documentation. You say that you would like the Plan to pay for this. The Plan denied your 
request. The Plan says this claim has been processed correctly. 
 
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 a 
comprehensive oral evaluation once every six months, panoramic radiographic imaging once every 60 months. 
This Plan does not cover risk assessment and documentation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and panoramic radiographic imaging have not been met. Risk 
assessment and documentation is not a covered benefit. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150), panoramic radiographic imaging (D0330), and risk 
assessment and documentation (D0601), provided by a participating provider on March 29, 2022, to April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care services provided on November 1, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care services. You say that it is the facilities responsibility to obtain 
prior authorization and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chronic care services provided on November 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 18, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
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 procedure code 76705 billed for date of service January 18, 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 July 
21, 2021. 
 
You asked the Plan to pay for the vision services. You say that that the clinic should be responsible for 
assigning you to an out of network provider. The Plan denied your request. The Plan says the procedure 
performed is not a Medicare approved procedure and is not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when completed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The records show that the services rendered was a new patient 
comprehensive eye exam and not a routine eye exam. Based on this information, we decided that the Plan's 
rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have 
to pay for the determination of refractive state (92015) provided July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 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 testing is not covered. 
 
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, a cardiovascular risk assessment panel, 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 laboratory services rendered on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on February 10, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you needed to have a tooth extracted and the 
services were medically necessary. The Plan denied your request. The Plan says local anesthesia (D9215) is not 
covered by your Plan's 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 local 
anesthesia (D9215) provided on February 10, 2022.