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

 
We decided that the Plan does not have to waive the coinsurance for the extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on September 11, 2023. We also decided that the 
Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) provided on 
September 11, 2023. 
 
You asked the Plan to waive the coinsurance for the extraction. You also asked the Plan to pay for the bone 
replacement graft for ridge preservation - per site. You say that you believe the bone graft was necessary. You 
also say that the bone graft in support of an implant should warrant at least some level of benefit. The Plan 
denied your request. The Plan says the coinsurance was appropriately applied to the extraction provided. The 
Plan also says a bone graft is not a contract benefit under the program. 
 
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 a 20% 
coinsurance for Category B basic restorative services which includes routine extractions. 
 
You have been asked to pay a 20% coinsurance for the extraction. This service falls within the Category B 
basic restorative 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 the extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on September 11, 2023.  
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation - per site (D7953) provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on September 25, 2023. 
 
You asked the Plan to pay for D0210. You say that you needed these images. 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 November 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) 
provided on September 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 10, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 February 7, 2023, and 
June 8, 2023. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) 
provided on October 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81314, 81345, and 
81272 for date of service July 24, 2023.  

You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 81314, 81345, and 81272 for date of 
service July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80306 and G0482 provided on June 14, 
2023. 
 
You asked the Plan to pay for procedure codes 80306 and G0482. 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 supported.  
The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT codes 80306 and G0482 are not supported in the medical record. Specifically, medical 
records submitted do not include an order that specifically list what test(s) are to be performed in the custom 
panel. Based on this information, we decided that Medicare rules for coverage of procedure codes 80306 and 
G0482 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80306 
and G0482 provided on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided on August 
30, 2023. 
 
You asked the Plan to pay for the Guardant360 CDx testing (81479). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that a valid unique identifier was 
reported. The unique identifier, Z031D, is not a valid code for the provided Guardant360 CDx testing. Based 
on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing (81479) have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing 
(81479) provided on August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 sensor. You say that the enrollee does meet the requirement 
of having recurrent level 2 hypoglycemic events. You also say that this monitor is absolutely medically 
necessary and indicated for this enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the CGM based on the information received. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not  use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental work needs to be done related to heart 
surgery that was done. You also say you cannot have any infections in your mouth because of the valve 
replacement. 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 maximum allotment for the requested item or service was reached on date of service August 28, 
2023. The record shows this claim was received September 7, 2023, which was after the maximum allotment 
had been reached. Therefore, we decided that the Plan does not have to pay for core buildup (D2950) provided 
on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the resin-based composite-four or more 
surfaces or involving an incisal angle (anterior) (D2335) provided on September 7, 2023. 
 
You asked the Plan to issue reimbursement for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item provided 
is not covered under the supplemental dental policy.  
 
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 item provided is not among those 
covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to issue reimbursement for the resin-based composite-four or 
more surfaces or involving an incisal angle (anterior) (D2335) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270) provided on October 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to your dentist on October 12, 2023, 
because a crown came off. You also say the dentist did two x-rays that day to check on the health of your tooth 
at this time. 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 March 9, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0270) provided on October 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair (PWC) with 
multiple power options. 
 
You asked the Plan to pre-approve a replacement PWC. You say that you want to appeal this denial. You also 
say that you were not aware this was denied as a result of your living situation. The Plan denied your request. 
The Plan says the current PWC is within its useful lifetime of five years. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested is shown to be for replacement of an identical or nearly identical item, due to wear. 
The case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home modifications, platform lift provided on May 17, 
2023. 
 
You asked the Plan to pay for home modifications, platform lift. You say that you would like reconsideration 
because the requested platform lift is medically necessary. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the home modifications, platform lift provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it 
was billed accurately. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, retainer crowns, pontics, and 
extractions (D2950 x3, D6740 x5, D6245, D7210 x2) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 Plan's 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 August 31, 2023. 
Therefore, we decided that the Plan does not have to pay for core buildup services, retainer crowns, pontics, 
and extractions (D2950 x3, D6740 x5, D6245, D7210 x2) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that your dentures have been adjusted but still 
do not fit properly and are causing you pain. The Plan denied your request. The Plan says your benefit for the 
requested 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 service was exhausted on date of service July 28, 2022. Therefore, we 
decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 14, 2023. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that the procedures were pre-
approved, but were denied once claims were submitted for payment. The Plan denied your request. The Plan 
says this service is not covered under the member's contract under any normal circumstances. 
 
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 
periodontal scaling and root planing (D4341) provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported porcelain fused to metal crown (D6059) 
provided on August 1, 2023. 
 
You asked the Plan to pay for abutment supported porcelain fused to metal crown. You say that you do not see 
any reason why this treatment is not covered by the Plan. The Plan denied your request. The Plan says this is 
not covered under your 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 pay for abutment 
supported porcelain fused to metal crown (D6059) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) provided on August 29, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you need new dentures because your previous 
dentures cracked. 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 the Plan paid for a complete upper denture (D5110) on February 9, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of February 9, 2023. Therefore, we decided that 
the Plan does not have to pay for a complete upper denture (D5110) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the free soft tissue graft (D4277) and the biological 
materials per site (D4265). 
 
You asked the Plan to pre-approve the free soft tissue graft (D4277) and the biological materials per site 
(D4265). You say that the services are medically necessary. The Plan denied your request. The Plan says the 
services are not covered 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 free soft tissue graft (D4277) and 
the biological materials per site (D4265) are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve the free soft tissue graft (D4277) and the biological materials per site 
(D4265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acute inpatient behavioral healthcare 
provided from June 16, 2023, through July 17, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided are not payable as they were rendered by an ineligible provider.  
 
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. 
 
A 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 issue reimbursement for the acute inpatient 
behavioral healthcare provided from June 16, 2023, through July 17, 2023.