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

 
We decided that the Plan does not have to pay for an extraction (D7210), an adjustment to a complete 
maxillary denture (D5140), and unspecified maxillofaxial prosthesis (D5999), provided by an out-of-network 
provider on December 7, 2020. 
 
You asked the Plan to pay for an extraction, an adjustment to a complete maxillary denture, and unspecified 
maxillofaxial prosthesis. You say that the Plan should pay for this. The Plan denied your request. The Plan says 
the annual limit allowed for the benefit year in question has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a $250 annual 
maximum for non-Medicare covered preventive and comprehensive dental services. 
  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an extraction, an adjustment to a complete maxillary denture, and unspecified maxillofaxial 
prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for an extraction 
(D7210), an adjustment to a complete maxillary denture (D5140), and unspecified maxillofaxial prosthesis 
(D5999), provided by an out-of-network provider on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #19 (D6056, D6010, 6059). 
 
You asked the Plan to pre-approve dental implants. You say that you disagree with the denial for dental 
services. The Plan denied your request. The Plan says prefabricated abutment (D6056), implant placement 
(D6010), and abutment supported metal crown (D6059) 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 pre-approve 
dental implants on tooth #19 (D6056, D6010, 6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by an 
out-of-network provider on January 27, 2022. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that this was part of a medical 
procedure and needed to be provided. The Plan denied your request. The Plan says medical records were not 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a panoramic radiographic image 
(D0330) provided by an out-of-network provider on January 27, 2022. The provider has failed to provide 
dental records to verify D0330 was medically necessary. Therefore, we decided that the Plan does not have to 
pay for a panoramic radiographic image (D0330) provided by an out-of-network provider on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for prophylaxis (D1110) provided on December 
13, 2021. 
 
You asked the Plan to waive the cost share for prophylaxis. You say that your dentist told you that you needed 
to have three cleanings per year. 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 there is a $0 
copayment for two cleanings (regular or periodontal maintenance). 
 
The record shows the Plan only pays for two cleaning per year, and you are responsible for the third cleaning. 
You have been asked to pay $110 for prophylaxis. Prophylaxis 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 waive the cost share for prophylaxis (D1110) provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81301 and 81455) provided on 
October 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81301 and 81455) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81275, 81276, 81301) provided October 
6, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81275, 81276, 81301) 
provided October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (36556, 76937, 93320, 93325) provided 
September 17, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 36556, 76937, 93320, & 93325 are not supported in the medical record. Specifically, 
these services are included in the base catheterization procedure and are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (36556, 76937, 93320, 93325) 
provided September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete mandibular dentures (D5120). 
 
You asked the Plan to pre-approve mandibular dentures. You say that the EOC does not clearly explain what is 
covered and what is excluded from coverage. The Plan denied your request. The Plan says one set of complete 
or partial dentures are covered every five years. 
 
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 one complete 
or partial denture every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan pre-approved 
coverage for complete maxillary dentures on March 25, 2022; therefore, the benefit for dentures has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve complete mandibular dentures 
(D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
January 14, 2022, to January 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that the rehab should be fully 
covered. 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 $300 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The record shows you were in the rehabilitation center from January 14, 2022, to January 15, 2022, but there is 
no copayment for the discharge date. Therefore, you have been asked to pay $300 for the first day of inpatient 
rehab. The inpatient rehab falls within the Inpatient Hospital Care 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 copayment for inpatient rehabilitation care provided from January 14, 2022, to January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided December 22, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC genes are a 
statutorily excluded service. 
 
We looked at the file and Medicare rules. The testing panel included the FANCC genes and is therefore non-
covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided 
December 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on January 7, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed  
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab reports clearly indicate 
that 15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately 
billable tests from the CPT Handbook. Based on this information, we decided that Medicare rules for coverage 
of the drug testing have been met. Additionally, the record indicates that this provider was directed by the Plan 
to not obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the 
physician signature. Therefore, we decided that the Plan has to pay for the drug testing provided on January 7, 
2019.  
 
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: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140), and extraction (D7210) provided 
from April 19, 2021, to April 20, 2021.  
 
You asked the Plan to pay for an evaluation and extraction. You say that you were unaware of any conditions 
for reimbursement and your concern was not to exceed your annual amount. The Plan denied your request. The 
Plan says that that this provider has opted out of Medicare and is not eligible for payment. 
 
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. The Plan did not provide enough information allowing us to confirm the 
provider's national provider identifier (NPI). 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. 
  
We are unable to confirm if the provider you received services from has opted out of Medicare, as the address 
location provided in the record is different than the one listed on the Medicare opt out website. We were also 
unable to confirm the provider's NPI based on the information provided by the Plan. Therefore, we decided 
that the Plan has to pay for a limited oral evaluation (D0140), and extraction (D7210) provided from April 19, 
2021, to April 20, 2021.   
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (G0482 and 80307) provided on May 23, 
2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that these services have been up coded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing services (G0482 and 80307) provided on May 23, 2018.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 5, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining prior authorization for all their patients, which should also cover medical treatments. 
The Plan denied your request. The Plan says the services were not urgent or emergent. It was also determined 
the services rendered could have been provided by a participating provider under the members Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions on tooth #'s 20, 21, 22, 23, 24, 25, 26, 27, 
28, and 29 by an oral surgeon. 
 
You asked the Plan to pre-approve extractions. You say that the extractions are medical necessary. The Plan 
denied your request. The Plan says dental services are not covered by an oral surgeon. 
 
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 
covered under this benefit when received by an oral surgeon. Therefore, we decided that the Plan does not have 
to pre-approve extractions on tooth #'s 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29 by an oral surgeon.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (80307 and G0482) provided on January 7, 2019. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that these services have been up coded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes have been tested in this case. Of note, we counted the classes based on the separately 
billable tests from the CPT Handbook. Additionally, the Plan has not provided any evidence as to why CPT 
code 80307 is not supported. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record indicates 
that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate for the 
Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing services have been met. Therefore, we decided that the Plan has 
to pay for drug testing services (80307 and G0482) provided on January 7, 2019.  
 
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.