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

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic test (D0431), localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) and 
periodontal maintenance (D4910) provided on December 2, 2021. 
 
You asked the Plan to pay for adjunctive pre-diagnostic test (D0431), localized delivery of antimicrobial agents 
via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) and periodontal maintenance 
(D4910). You say that the services should be covered. The Plan denied your request. The Plan says procedure 
was 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested adjunctive pre-diagnostic 
test (D0431), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular 
tissue, per tooth (D4381) are not among those covered under this benefit. Periodontal maintenance (D4910) 
was not covered, you previously had this procedure on April 19, 2021, and August 23, 2021, which is the 
maximum limit of two per calendar year. Therefore, we decided that the Plan does not have to pay for 
adjunctive pre-diagnostic test (D0431), localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue, per tooth (D4381) and periodontal maintenance (D4910) provided on 
December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 26, 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 March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 18, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you had to see your dentist and an oral surgeon on 
the same day due to an emergency. The Plan denied your request. The Plan says this service is covered by the 
Plan's dental benefits; however, your benefit for one limited oral evaluation (D0140) per Plan year has been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation (D0140) per Plan year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on January 18, 2022; therefore, the benefit for a limited oral evaluation has been 
exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service January 15, 2022. 
 You asked the Plan to pay for procedure code. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code is bundled into 
payment for a code. 
 
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 70450 
is a column II code to column I code 70496. 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 billed for date of service January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails provided on November 11, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement of nails. You say that the facility would only allow certain 
providers into their facility to render service to the enrollee; therefore, 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 debridement of nails provided on November 
11, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, and 81321 
provided on November 2, 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, 81235, and 81321 are not supported in the medical record. Specifically, if a 
laboratory assays two more genes in an enrollee in parallel, then those two or more genes will be considered 
part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the 
panel. Review of the file does not support that one code was submitted for the panel 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, 81235, and 
81321 provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2752) and core build up (D2950) for tooth # 18. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has extreme sensitivity and 
discomfort when masticating. You also say that a composite resin restoration will not provide a good long-term 
prognosis. The Plan denied your request. The Plan says that the requested 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 the dental 
services 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 the dental services. Our reviewer says 
that the requested core build up and crown for tooth # 18 are medically necessary. Our physician reviewer 
found the documentation indicates that there is distal caries and what appears to be an occlusal crack extending 
mesial to distal. The reviewer found that the enrollee's symptoms are pain with mastication which indicates a 
cracked tooth. Therefore, the reviewer found that the requested core buildup and crown restoration for tooth # 
18 are medically reasonable to treat this and prevent further fracture of the tooth. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2752) and core build up (D2950) for tooth # 18.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin testing provided on January 13, 2022. 
 
You asked the Plan to pay for the testing services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the service is not a Medicare benefit for the diagnosis 
listed. 
 
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 83036 is hemoglobin; glycosylated (A1C). We find that 
CPT code 83036 is not supported in the medical record. The service at issue, when used to detect an 
undiagnosed disease or disease predisposition is not a Medicare benefit. 
 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 hemoglobin testing provided on January 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided from March 2, 
2021, to December 15, 2021.  
 
You asked the Plan to pay for periodontal maintenance. You say that you do not understand why your 2021 
claims were denied for the same services you also received in 2020. The Plan denied your request. The Plan 
says this 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 Plan contract says that supplemental dental 
services are covered when provided by any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare. 
 
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 
periodontal maintenance (D4910) provided from March 2, 2021, to December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77067, 77063) provided January 26, 
2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 code 77067, & 77063 is not supported in the medical record. Specifically, these codes were 
already paid for the date of service at issue. Records do not support an additional instance of these codes. Based 
on this information, we decided that Medicare rules for coverage of the radiology services have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for radiology services (77067, 77063) provided 
January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81235, 81321) provided on 
April 26, 2021. 
 You asked the Plan to pay for the laboratory 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 in 
accordance with Medicare billing 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 laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81206, 81235, 81321) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
December 23, 2021, to January 20, 2022. 
 
You asked the Plan to pay for dental services. You say that there is a lack of in-network providers. The Plan 
denied your request. The Plan says prior authorization was not obtained for these 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 Plan covers dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network on December 23, 2021, to January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ExoDx Prostate Test. 
 
You asked the Plan to pay for the test. The Plan denied your request. The Plan says this test 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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
the ExoDx Prostate Test has been tested in men 50+ years of age with a PSA level between 2 and 10mg/mL 
who are considering an initial or repeat prostate biopsy. The documentation in the case file does not support 
that the requested ExoDx genetic testing is medically reasonable and necessary for the enrollee in this case. 
The enrollee has had 3 prior negative biopsies and has a PSA that is lower than it was previously.  
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the ExoDx Prostate Test.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 35 hours per week of home health aide (HHA) services 
(reduced to 16.5 hours per week). 
 
You asked the Plan to pre-approve the requested number of HHA hours. You say that you feel that the number 
of hours you have been reduced to is not sufficient. The Plan denied your request. The Plan says you do not 
require the 35 hours per week of HHA services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 requested number of HHA hours. 
Our reviewer says that the requested number of HHA hours is not shown to be medically reasonable and 
necessary. Our physician reviewer found the member is medically stable without any recent hospitalizations or 
medical complications. The approved weekly hours of HHA services allow for appropriate support and care. She is able to receive informal support from her husband and benefits from the homemaking services that 
are available to him. The documentation does not support that the additional hours are needed to provide 
adequate support for the member. 
 
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 number of HHA hours have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 35 hours per week of home health aide (HHA) services (reduced to 
16.5 hours per week).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210). 
 
You asked the Plan to pre-approve an extraction. You say that you need the dental services because you are a 
diabetic. The Plan denied your request. The Plan says an extraction (D7210) is not covered when performed 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 
among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve an extraction (D7210).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total shoulder arthroplasty. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant placement (D6010), bone graft at implant 
placement (D6104), guided tissue regeneration (D4266), and surgical extraction (D7210) provided on March 
24, 2021. 
 
You asked the Plan to pay for the dental services provided on March 24, 2021. You say that you requested 
reimbursement in November 2021. You say that you have not received any response. The Plan denied your 
request. The Plan says that the annual maximum benefit of $500 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit of $500 
has been exhausted. The record shows that the Plan paid $166 for dental services received on requested items 
or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the implant placement (D6010), bone graft at implant placement (D6104), guided tissue regeneration 
(D4266), and surgical extraction (D7210) provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (6750) provided by an out-of-network 
provider on February 8, 2022. 
 
You asked the Plan to pay for a retainer crown. You say that the Plan should pay for 50% of this. The Plan 
denied your request. The Plan says the dental service that was provided 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. 
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of a retainer crown have not been met. Therefore, we decided that 
the Plan does not have to pay for a retainer crown (6750) provided by an out-of-network on February 8, 2022.