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

 
We decided that the Plan does not have to pay for a palliative treatment procedure (D9110), and the repair of a 
broken complete mandibular denture (D5511) provided on June 26, 2023, to June 27, 2023. 
 
You asked the Plan to pay for D9110 and D5511. You say that you feel like you were misled by the 
representative. The Plan denied your request. The Plan says the denied dental 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 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 
palliative treatment procedure (D9110), and the repair of a broken complete mandibular denture (D5511) 
provided on June 26, 2023, to June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulpal debridement (D3221) provided on June 7, 2023.

You asked the Plan to pay for D3221. You say that you were told that there would be no out-of-pocket charges for this visit. The Plan denied your request. The Plan says D3221 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 Plan's 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 pulpal debridement (D3221) provided on June 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI and specialist visit provided from 
July 5, 2023, to July 17, 2023. 
 
You asked the Plan to waive the copayment for an MRI and specialist visit. You say that you disagree with the 
cost share applied. 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 a $170 
copayment for outpatient diagnostic tests and a $35 copayment for a specialist visit.  
 You have been asked to pay a $205 copayment for an MRI and specialist visit. This total includes a $170 
copayment for an MRI and a $35 copayment for a specialist visit. The MRI falls within the outpatient 
diagnostic tests benefit category. The specialist visit falls within the physician/practitioner 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 copayment for an MRI and specialist visit provided from July 
5, 2023, to July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on September 19, 2022, to, 
November 28, 2022. 
 
You asked the Plan to pay for  acupuncture services. You say that you are suffering from lower back and leg 
pain and were told that you were not a candidate for surgery. The Plan denied your request. The Plan says the 
acupuncture services were provided by an unqualified provider. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for  acupuncture services provided on September 19, 2022, to, November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on May 11, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you always get a denial of payment and 
wonder why you have this insurance. The Plan denied your request. The Plan says your benefit for the limited 
oral evaluation 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 April 21, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided 
on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acoustic compressive therapy and pulsed electromagnetic 
field therapy provided by a chiropractor on May 4, 2023, to June 22, 2023. 
 
You asked the Plan to pay for the acoustic compressive therapy and pulsed electromagnetic field therapy. You 
say that the treatments helped heal your fractures. The Plan denied your request. The Plan says that 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 acoustic compressive therapy and pulsed electromagnetic field therapy 
provided by a chiropractor on May 4, 2023, to June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an orthopedic visit provided on February 
22, 2023. The Plan addressed the visit on March 24, 2023, and has been overturned. 
 
You asked the Plan to waive the deductible for an orthopedic visit. You say that you should not have to pay 
these large amounts. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Physician/Practitioner services, 
including doctors office visits. You have been asked to pay $161.95 towards that $750 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Physician/Practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
orthopedic visit was received on February 22, 2023.  Therefore, we decided that the Plan does not have to waive the deductible for an orthopedic visit provided on 
February 22, 2023. The Plan addressed the visit on March 24, 2023, and has been overturned.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core and retreatment of previous 
root canal therapy (D2954, D3347) provided on March 7, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the retreatment of previous root 
canal therapy has already been exhausted. Additionally, the cost-sharing applied correctly based on the services 
provided. 
 
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 retreatment of previous root canal therapy was exhausted on date of service 
February 16, 2021 (D3347). 
 
You have been asked to pay a 50% coinsurance for a prefabricated post and core. 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 pay for a prefabricated post and core and 
retreatment of previous root canal therapy (D2954, D3347) provided on March 7, 2023, to May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 1, 2023, billed with 
codes 81209, 81216, 81242, 81279, 81298, 81307, 81311, 81317, 81321, 81334, and 81339. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 
May 1, 2023, billed with codes 81209, 81216, 81242, 81279, 81298, 81307, 81311, 81317, 81321, 81334, and 
81339.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) and Vivex mesenchymal 
stem cell allograft (20930). 
 
You asked the Plan to pre-approve bone marrow aspirate and Vivex mesenchymal stem cell allograft. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate and Vivex mesenchymal stem cell allograft. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate and stem 
cell allograft are experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate and Vivex mesenchymal stem cell allograft have not been 
met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939) and 
Vivex mesenchymal stem cell allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport brackets for an ultralightweight manual 
wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested transport brackets do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve transport brackets for an ultralightweight manual 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #2 and to pay for the core 
buildup (D2950) for tooth #2 provided on May 25, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan's website said the provider was 
in-network. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 $133 for dental services on March 14, 2023. On March 24, 2023, the Plan paid $1,264.80 
for dental services. On March 25, 2023, the Plan paid $1,602.20 for dental services. For the year of 2023 the 
Plan paid $3,000 ($133 paid + $1,264.80 paid + $1,602.20 paid) for dental services; therefore, your annual 
dental maximum benefit for the year of 2023 was exhausted on the date of service of May 25, 2023. Therefore, 
we decided that the Plan does not have to pay more for a crown (D2740) for tooth #2 and to pay for the core 
buildup (D2950) for tooth #2 provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 May 26, 2022. Therefore, 
we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530 x 4), chiropractic 
manipulative treatment extraspinal (98943 x 4) and office visit provided by a chiropractor (99202) from May 
26, 2023, to June 15, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that chiropractic treatment is indicated for 
your spinal stenosis and these services relate to that treatment and should be covered. The Plan denied your 
request. The Plan says these chiropractic services are excluded from coverage. 
 
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 therapeutic activities (97530 x 4), chiropractic manipulative treatment 
extraspinal (98943 x 4) and office visit provided by a chiropractor (99202) from May 26, 2023, to June 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 21, 2023.. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you disagree with the copayment. 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 a $32 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $32 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 [Waive/Reduce] the 
copayment for a specialist office visit provided on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 300 OneTouch Verio test strips. 
 
You asked the Plan to pre-approve the test strips. The Plan denied your request. The Plan says current quantity 
restriction for the requested test strip is: 100 test strips per 90-day supply for non-insulin users and 400 test 
strips per 90-day supply for insulin users. 
 
The Plan must follow Medicare rules. Medicare rules say that a beneficiary who is currently being treated with 
insulin administrations, up to 300 test strips and up to  300 lancets every 3 months are covered if basic 
coverage criteria (1)-(2) (above) are met. 
 
We looked at the file and Medicare rules. The Plan has verified with the provider you test once a day and not 3 
times daily. Based on this information, we decided that Medicare rules for coverage of the test strips have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 300 OneTouch Verio test strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on June 28, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the home or residence visit. You say that authorization should have been 
obtained by the facility or patients referring physician. The Plan denied your request. The Plan says the out-of-
network services were not authorized.  
 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 a home or residence visit provided on June 28, 
2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure and placement of intra-
socket biological dressing (D7922, D1999) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
unspecified preventive procedure and placement of intra-socket biological dressing (D7922, D1999) provided 
on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-rays, bitewing x-rays, 
and cleaning (D0274, D0120, D0230, D0220, D1110) provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 periodic oral evaluation, intraoral x-rays, bitewing x-rays, and cleaning (D0274, D0120, D0230, 
D0220, D1110) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam 3D scan (D0363) provided on July 7, 2023. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your dental 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 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 cone 
beam 3D scan (D0363) provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on January 30, 
2023. 
 
You asked the Plan to pay for procedure code 0012M. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on January 30, 2023.