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

 
We decided that the Plan does not have to pay more for the resin-based composite, crown and prefabricated 
post and core. 
 
You asked the Plan to pay more for resin-based composite, crown and prefabricated post and core. You say that 
you feel you are being over charged for services. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
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 Plan is only obligated to pay 80% 
of the allowed amount for the resin-based composite and post and core in addition to crown. The Plan is only 
obligated to pay 50% of the allowed amount for the crown. You are responsible for any amount greater than 
what the Plan pays to the out-of-network provider. Therefore, we decided that the Plan does not have to pay 
more for the resin-based composite provided on December 13, 2021, and the crown and prefabricated post and 
core in addition to crown provided on December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a muscle, myocutaneous, or fasciocutaneous flap. 
 
You asked the Plan to pre-approve a muscle, myocutaneous, or fasciocutaneous flap. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 a muscle, myocutaneous, or 
fasciocutaneous flap. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you do not have an abdominal wall hernia, 
and the medical necessity for a muscle, myocutaneous, or fasciocutaneous flap has not been demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a muscle, myocutaneous, or fasciocutaneous flap.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional months of dynamic splint rental (E1800, 
E1805). 
 
You asked the Plan to pre-approve 6 additional months of dynamic splint rental. You say that the enrollee's 
doctor said these items are necessary. The Plan denied your request. The Plan says an additional 6 months' 
rental is not medically necessary 
 
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 6 additional months of dynamic splint 
rental. Our reviewer says that the requested item rental is not considered medically reasonable and necessary in 
this case. Our physician reviewer found while the records show that the enrollee needs these items, as 6 months 
have been approved, additional rental time is not supported  prior to re-evaluation. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional months of dynamic splint rental have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional months of dynamic splint rental (E1800, E1805).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reduce the cost sharing for the panoramic film, oral evaluation, prophylaxis, 
bitewings, resin-based composite, two surfaces and resin-based composite, three surfaces provided from 
January 6, 2022, to January 24, 2022. 
 
You asked the Plan to reduce the cost sharing for the panoramic film, oral evaluation, prophylaxis, bitewings, 
resin-based composite, two surfaces and resin-based composite, three surfaces. You say that you were given 
incorrect information from the provider, and you want the claims adjusted to allow at the in-network rate.  The 
Plan says that 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. Your 
contract with the Plan clearly says that enrollees must pay 50% coinsurance for covered preventive and 
comprehensive dental services. The Plan contract also says that enrollees only have to pay the cost sharing 
amount when they get services covered by the plan. The contract also says you cannot be balance billed. 
 
The Plan says you must pay 50% coinsurance for panoramic film, an oral evaluation, prophylaxis, and 
bitewings, resin-based composite, two surfaces and resin-based composite, three surfaces, plus the difference 
between what was charged by the provider and the allowed amount. Based on the Plan contract, however, you 
cannot be asked to pay more than 50% of the allowed amount for covered preventive and comprehensive dental 
services. Therefore, we decided that the Plan has to reduce the cost sharing for the panoramic film (code 
D0330), an oral evaluation (code D0150), prophylaxis (code D1110), bitewings (code D0274), resin-based 
composite, two surfaces (code D2392) and resin-based composite, three surfaces (code D2393) provided from 
January 6, 2022, to January 24, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from and can tolerate an 
intensive interdisciplinary treatment program of 3 hours therapy per day 5 days per week under the supervision 
of a physician. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to 
an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve early replacement of a portable oxygen concetrator. 
 
You asked the Plan to pre-approve a portable oxygen concetrator. You say that your current device is 
displaying a warning sign. Something is not right with your current device, and you do not trust it to work properly. You do not understand why you cannot get a new one before September 2022. The Plan denied your 
request. The Plan says you are not eligible for an upgrade to a new device until 09/19/2022. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen concetrator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve early replacement of a portable oxygen concetrator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for urgent care center services provided on May 6, 2020. 
 
You asked the Plan to pay for urgent care center services. You say that the claim was filed timely. The Plan 
denied your request. The Plan says that the claim was filed untimely. 
 
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 has not provided us with documentation to support the denial. 
Therefore, we decided that the Plan has to pay for urgent care center services provided on May 6, 2020.  
 
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 Mandibular Partial Denture on February 18, 2022. 
 
You asked the Plan to pay for Mandibular Partial Denture. You say that you went to a separate dentist. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
can be received in-network. 
 
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 
Mandibular Partial Denture on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0230), limited oral evaluation (D0140), 
and extraction (D7140) provided on March 7, 2022. 
 
You asked the Plan to pay for an x-ray, evaluation, and extraction. You say that you called the insurance 
company to schedule a dentist appointment and they gave you a dentist that was not in-network. The Plan 
denied your request. The Plan says that these services are covered by your Plan's dental benefits; however, 
services received from an out-of-network dentist 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. 
 
The record shows you received dental services at a location that the dentist was out-of-network. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered by 
an out-of-network dentist. Therefore, we decided that the Plan does not have to pay for a periapical x-ray 
(D0230), limited oral evaluation (D0140), and extraction (D7140) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation  problem focused (code D0140) 
provided on February 16, 2022. 
 
You asked the Plan to pay for a limited oral evaluation-problem focused. You say that you disagree with the 
denial, and you feel this should be covered. The Plan denied your request. The Plan says a limited oral 
evaluation  problem focused (code D0140) is not covered by your health Plan or Medicare. 
 
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.  
 
We looked at the file and Medicare rules. The file shows that the Plans dental benefit does not provide 
coverage for a limited oral evaluation-problem focused (code D0140). Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation  problem focused (code D0140) provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on September 21, 2021. 
 
You asked the Plan to pay for code 83789. 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 looked at the file and the rules. We find that CPT code 83789 was billed for specimen validity testing. Validity testing on urine specimens used for drug testing shall not be separately billed. Therefore, we decided 
that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided 
on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare 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 testing is an NGS panel which 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 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on July 7, 2021, billed with code 88104. 
 
You asked the Plan to pay for the testing as billed. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this service was already paid on a previous claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  
 
We looked at the file and Medicare rules. Review of the file shows that payment was made for code 88104 on a 
previous claim. As such, this line item was correctly denied as duplicate. Based on this information, we decided 
that Medicare rules for coverage of the testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the testing provided on July 7, 2021, billed with code 88104.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 
provided on October 17, 2021 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 81206, 81292, and 81301 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code should be submitted for the 
entire panel. Review of the file shows that more than one code was billed for the services provided. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 
81301 provided on October 17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #28 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says these services are not medically necessary. 
 
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 the 
criteria for coverage are not met. Our physician reviewer found that for consideration of a crown there must be 
at least three surfaces involved and one cusp. In this instance there is minimal damage to the tooth structure, 
and no clear need for a full coverage restoration. As there is minimal structural loss and no clear caries that 
would further damage the tooth to the extent the criteria requires, there is no necessity for a crown on tooth 
#28. 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 on tooth #28 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contact lens fitting exam provided on February 11, 2022. 
 
You asked the Plan to pay for a contact lens fitting exam. You say this should be covered. The Plan denied 
your request. The Plan says contact lens fitting exam is not a covered benefit. 
 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.  
 
We looked at the file and the Plan's rules. The file shows that a contact lens fitting exam is not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for a contact lens fitting exam provided on 
February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for dental crowns, porcelain/ceramic (code D6740) 
provided on October 20, 2021. 
 
You asked the Plan to reimburse you for dental crowns, porcelain/ceramic. You say that you had an accidental 
fall and suffered serious facial trauma requiring these dental services, which you believe should be covered by 
the Plan either under dental or medical benefits. The Plan denied your request. The Plan says the services 
requested are dental in nature and are unrelated to the limited clinical indications and are not covered under the 
medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for dental 
crowns, porcelain/ceramic (code D6740) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assessment of a patient (D0191) rendered on May 17, 
2021, and a comprehensive oral evaluation (D0150) provided on May 20, 2021. 
 
You asked the Plan to pay for an assessment of a patient rendered on May 17, 2021, and a comprehensive oral 
evaluation. You say that you went to the appointment set up for you and they put you in a room, and before 
they started, they moved you to another room. You also say you then ended up with the other doctor, and they 
did not do a cleaning. The Plan denied your request. The Plan says comprehensive oral exams are covered once 
every 36 months and you last received a comprehensive oral evaluation on March 13, 2019. The Plan also says 
that the assessment of a patient is a non-covered service under the member's routine 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 an 
assessment of a patient (D0191) rendered on May 17, 2021, and a comprehensive oral evaluation (D0150) 
provided on May 20, 2021.