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

 
We decided that the Plan does not have to issue additional payment for the semi-precision abutment-
placements (D6191 x 4), semi-precision attachment-placements (D6192 x 4), unspecified removable 
prosthodontic procedure, by report (D5899), reline of a complete upper denture (D5750), a complete upper 
denture (D5110), and the implant/abutment supported removable denture for a lower arch (D6111) provided 
from January 13, 2023, through March 22, 2023. 
 
You asked the Plan to issue additional payment for the dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the items/services provided 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 items/services provided was exhausted on date of service January 13, 2023. 
Specifically, the Plans contract states that the Plan pays up to $2,500 every year for nonMedicare covered 
preventive dental services and nonMedicare covered comprehensive dental services combined. You are 
responsible for any amount above the dental coverage limit. The record shows that the Plan issued payments in 
the total amount of $2,500 ($1,023.20 + $1,476.80) for dental services provided in the 2023 calendar year. 
Therefore, you have exhausted the allowable benefit for the items/services provided in this case. Therefore, we 
decided that the Plan does not have to issue additional payment for the semi-precision abutment-placements 
(D6191 x 4), semi-precision attachment-placements (D6192 x 4), unspecified removable prosthodontic 
procedure, by report (D5899), reline of a complete upper denture (D5750), a complete upper denture (D5110), 
and the implant/abutment supported removable denture for a lower arch (D6111) provided from January 13, 
2023, through March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visual field examination provided on September 23, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the visual field examination. You say that you were told that this service was 
covered under your plan. You say you need the service because you are losing your eyesight. The Plan denied 
your request. The Plan says the provider was out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
visual field examination. We found no exception that would require the Plan to pay for the visual field 
examination. Therefore, we decided that the Plan does not have to pay for the visual field examination provided 
on September 23, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 28, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the necessary 
documents. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 19, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 
19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the first periapical x-
ray (D0220) provided on August 2, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140) and the first periapical x-ray (D0220). You 
say that you have resubmitted this claim numerous times since the date of service to keep it timely due to no 
payment. The Plan denied your request. The Plan says the services exceed timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the limited oral evaluation (D0140) and the first periapical x-ray (D0220) 
was not filed until August 17, 2023. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and the first periapical x-ray (D0220) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation with a medicinal agent-per quadrant 
(D4921 x 4), oral hygiene instructions (D1330), and the topical application of fluoride varnish (D1206) 
provided on August 31, 2023. 
 
You asked the Plan to pay 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 gingival irrigation services and the oral 
hygiene instructions provided are not covered under the supplemental dental policy. Additionally, you have 
exhausted the allowable benefit for the topical application of fluoride varnish provided in this case.  
 
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 gingival irrigation services and the 
oral hygiene instructions provided are not among those covered under this benefit. Additionally, you have 
exhausted the allowable benefit for the topical application of fluoride varnish provided in this case. 
Specifically, the Plans contract states that one topical fluoride treatment is covered per year. You previously 
received this service on May 24, 2023, less than one year prior, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay 
for gingival irrigation with a medicinal agent-per quadrant (D4921 x 4), oral hygiene instructions (D1330), and 
the topical application of fluoride varnish (D1206) provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 2, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
information. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you did not wait six months 
for this cleaning. 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 2, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on June 24, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on June 
24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232) 
provided on March 3, 2022. 
 
You asked the Plan to pay for the hospital care. You say that please process this claim for payment. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until April 27, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232) provided on 
March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 31, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full arch occlusal guard (D9944) provided on July 18, 
2023. 
 
You asked the Plan to pay for a full arch occlusal guard. You say that this is for your jaw alignment and not for 
grinding your teeth (which you do not do). You also say you have a great need for this, and it should be 
considered. The Plan denied your request. The Plan says this 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 pay for a full arch 
occlusal guard (D9944) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy and the electrical stimulation 
provided by a chiropractor on September 19, 2023. 
 
You asked the Plan to pay for the mechanical traction therapy and the electrical stimulation. You say that you 
pursued spinal decompression because prior treatments were not giving you the most possible relief for your 
back. issues. You say that you have tried spinal manipulation and physical therapy, which did not provide you 
any relief. You say that after getting a magnetic resonance imaging (MRI) on your back, your physician 
advised that the best treatment would be spinal decompression. The Plan denied your request. The Plan says the 
only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy and the electrical stimulation provided by a 
chiropractor on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 extractions (D7210), and lower partial denture with 
flexible base (D5226) provided on July 13, 2023, by an opt-out provider. 
 
You asked the Plan to pay for the dental services. You say that you had gone to this provider previously when 
you had different coverage. You say that you were unaware the provider was not in-network. You also say that 
you were advised by the office that you would need to pay out-of-pocket and seek reimbursement from your 
insurance company. The Plan denied your request. The Plan says services performed by a provider that has 
opted out of Medicare 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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the services performed by an opt-out 
provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the 2 extractions (D7210), and lower partial denture with flexible base (D5226) provided on July 13, 
2023, by an opt-out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 23, 2023. 
 
You asked the Plan to pay for the supply allowance for the CGM. You say that you have provided all the 
required documents and you would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on July 7, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and you would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the 
related supply allowance provided by an out-of-network provider on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
June 24, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with 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 a continuous glucose monitor (CGM) 
(A4239) provided on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
October 12, 2023. 
 
You asked the Plan to pay for the dental service. You say that you received the services as a follow up to an 
injury you received previously. 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 February 8, 2022. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on October 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 28, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had to have multiple visits to the dentist 
because of your tooth. 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 limited oral evaluation (D0140) on July 24, 2023, and July 26, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of July, 26, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 28, 
2023.
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 
November 7, 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 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 dental services provided by an out-of-network provider on November 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
January 19, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says the unbundling of lab codes for PCR panel 
testing is not appropriate.  
 
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 Altru Dx UTI-ABR Molecular Test Panel provided on January 19, 2023, and 
billed with codes 87481, 87653, 87798, and 87801.