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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on April 5, 2022, and endodontic therapy (D3330) provided on April 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that verbal authorization was given by the Plan for 
these services. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. 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 from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on April 5, 2022, and 
endodontic therapy (D3330) provided on April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2394), a periodic oral evaluation 
(D0120), prophylaxis (D1110), and bitewings (D0274), provided by an out-of-network provider on April 21, 
2022 
 
You asked the Plan to pay for the dental services. You say that you believe that these services should be 
covered and paid. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. 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 from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a resin-based composite (D2394), a periodic oral evaluation (D0120), prophylaxis (D1110), and 
bitewings (D0274), provided by an out-of-network provider on April 21, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periodontal maintenance 
(D4910), and fluoride (D1208) provided on February 15, 2021, and a periodic oral evaluation (D0120) and 
fluoride (D1208) provided on August 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your provider has opted out of Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120), periodontal maintenance (D4910), and fluoride (D1208) provided on February 15, 
2021, and a periodic oral evaluation (D0120) and fluoride (D1208) provided on August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is disabling. The 
Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 therapeutic continuous glucose 
monitor (CGM) and sensor. 
 
You asked the Plan to pre-approve the CGM and sensor. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and sensor. Our reviewer says 
that the requested CGM and sensor are not medically reasonable and necessary. Our physician reviewer found 
that the enrollee is not taking more than 1 shot of insulin, and as such, does not meet the coverage criteria.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM and sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Freestyle Libre 2 therapeutic continuous glucose monitor (CGM) and sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on June 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provided is not 
enrollee in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services you received on June 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022, billed with 
codes 81455, 81301, 81479, 81194, and 81436. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was a medically necessary 
covered service. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 28, 2022, billed with codes 81455, 81301, 81479, 81194, and 81436.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional outpatient physical therapy visits. 
 
You asked the Plan to pre-approve the outpatient visits. You say that when you had surgery for a nerve block, it 
damaged the nerve to your hand. You have been working with your hand to get it corrected and need more 
physical therapy visits. The Plan denied your request. The Plan says the additional visits are not medically 
necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found on review of the available records, the enrollee with history as above 
does not meet CMS /LCD coverage criteria for the requested additional therapy visits. The enrollee has chronic 
pain and has had improvement with therapy and home exercise should maintain the gains made in therapy. The 
documentation does not support the need for additional physical therapy visits which are not medically 
necessary for coverage. Additional visits are not medically necessary or reasonable based on the review of 
documentation by Physical therapist and I agree with the denial of the additional visits for skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional outpatient physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment-includes placement (D6057) and 
abutment supported porcelain/ceramic crown (D6058) provided on May 5, 2022. 
 
You asked the Plan to pay for dental services. You say that this was an important dental service, and you would 
like the Plan to cover the cost. The Plan denied your request. The Plan says this service is not covered 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. Custom fabricated abutment-
includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not covered under 
the Plan's dental benefit. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested custom fabricated abutment-includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom fabricated abutment-includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 87801. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87801 is bundled into payment for code 87500. 
 
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 87801 
is a column II code to column I code 87500. 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 87801 billed for date of service January 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need replacement dentures. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 31, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), periodontal scaling and 
root planing (D4342), localized delivery of antimicrobial agents (D4381), and prophylaxis (D1110), provided 
by an out-of-network provider on January 26, 2022, to May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. 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 from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal maintenance (D4910), periodontal scaling and root planing (D4342), localized delivery 
of antimicrobial agents (D4381), and prophylaxis (D1110), provided by an out-of-network provider on January 
26, 2022, to May 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for services provided on May 
10, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 76775 is ultrasound, retroperitoneal (e.g., renal, aorta, 
nodes), real time with image documentation; limited.  
 
 We find that CPT code 76775 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76775 billed for services provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown on tooth #3 (D2740) provided on 
February 16, 2022. 
 
You asked the Plan to waive the coinsurance for a crown. You say that you have multiple dental insurances, 
and you should not have any out-of-pocket costs for dental services. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 50% 
coinsurance for covered comprehensive dental services.  You have been asked to pay $352.50, which is 50% coinsurance of the allowed amount for a crown ($705 
allowed amount x 50% coinsurance = $352.50). This item/service 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 coinsurance for a crown on tooth #3 (D2740) provided on 
February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #4 and retainer crowns 
(D6750) for tooth #'s 3 and 5. 
 
You asked the Plan to pre-approve a pontic and retainer crowns. You say that you cannot afford to pay for 
these services. The Plan denied your request. The Plan says this request does not meet the criteria for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic and 
retainer crowns 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 pontic and retainer crowns. Our 
reviewer says that given the criteria provided, there would be no necessity for a posterior fixed bridge as 
requested under the Plan. Our physician reviewer found tooth #'s 4 and 14 are missing in the upper arch, with 
no missing anterior teeth. Our reviewer found that the Plan limitations would not allow for a fixed bridge for 
posterior teeth as is the case here, replacing tooth #4. Our physician reviewer also found that the proposed 
treatment is reasonable, but not necessary, as alternatives exist. 
 
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 pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6240) for tooth #4 and retainer crowns (D6750) for tooth #'s 3 
and 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the removal of residual tooth roots 
(cutting procedure) (D7250), extractions, erupted tooth or exposed root (elevation and/or forceps removal) 
(D7140), and unspecified removable prosthodontic procedure (D5899) provided April 26, 2022. 
 
You asked the Plan to provide additional payment for the dental services. You say that you were quoted a 
lower cost for these services. The Plan denied your request. The Plan says the services have processed correctly 
according to your 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, certain limitations apply. The record 
shows your benefit for the cutting procedure was exhausted on the same date of service April 26, 2022. Your 
benefit does not list unspecified removable prosthodontic procedures as a covered service. The record also 
shows that your $2,000 annual dental allowance was exhausted on April 26, 2022. Therefore, we decided that 
the Plan does not have to provide additional payment for the removal of residual tooth roots (cutting procedure) 
(D7250), extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and 
unspecified removable prosthodontic procedure (D5899) provided April 26, 2022.  
 
Your complaint about your quoted cost being lower than the amount you are being asked to pay is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 19, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81328, 81355, and 81407. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 19, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 
81328, 81355, and 81407.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 23, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on June 23, 2022 by an 
out-of-network (OON) provider.