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

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, intraoral x-rays and 
bitewing x-rays provided on December 9, 2019. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, intraoral x-rays and bitewing x-rays. 
You say that he was unaware that he was only allowed a one-time calendar year checkup examination. You say 
that he was not informed he would need to pay out of pocket for this visit. The Plan denied your request. The 
Plan says the dental benefit was 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, the Plan also has a maximum benefit 
of one oral exam, x-ray and prophylaxis per year. The Plan paid for an oral exam provided on January 4, 2019 
and a prophylaxis and bitewing x-rays provided on May 22, 2019, which exhausted the benefits. Therefore, we 
decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, intraoral x-rays and 
bitewing x-rays provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee and billed under code 99152 for January 30, 2020. You asked the Plan to pay for code 99152. We note the Plan paid for code 99153. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. 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 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 code 99152. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided do not include documentation to corroborate the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status was there during the procedure, therefore criteria is not met for the description in the definition for CPT code 99152, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99152. We note the Plan paid for code 99153 have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee and billed under codes 99152 and 99153 for January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on March 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that these drugs were administered for a 
cataract operation. The Plan denied your request. The Plan says this drug is a self-administered drug, and is not 
Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on March 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
February 14, 2020. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee was not 
enrolled in hospice during the time of transport. You also say that hospice had been terminated as of February 
10, 2020, and was not invoked again until February 25, 2020. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 10, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service and ground mileage provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and bone replacement graft provided on March 10, 2020.

You asked the Plan to pay for the extraction and bone replacement graft. You say that the extraction and bone graft were necessary to restore the area. You say that you are requesting reimbursement. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extraction and bone replacement graft provided on March 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 10, 2020 by the out of network provider.

You asked the Plan to pay for the laboratory services. You say that the claim denied because the enrollee was enrolled in hospice on the date of service. You say that this is incorrect. You also say that when using the Medicare tool to verify Medicare eligibility, it says that hospice effective July 1, 2020. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on June 1, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 10, 2020 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) and 
the unlisted preventive dental service (D1999) provided from May 5, 2020, to May 19, 2020. 
 
You asked the Plan to pay the in network rate for the oral evaluation and unlisted preventive dental service. 
You say that your in network dentist referred you to this office for the services. You say that you were advised 
by a plan representative that this office was in network. You say that you cannot afford to pay these bills. You 
also say that you would not have gone to this office had you been advised that they were out of network. The 
Plan denied your request. The Plan says 2 evaluations are covered per calendar year. The Plan says that the 
frequency limit for oral evaluations has been exceeded. The Plan also says that the unlisted preventive dental 
service is not listed as a covered service. 
 
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 and oral evaluations are listed as a 
covered service, the frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan 
paid for oral evaluations that you received on February 2, 2020, and June 25, 2020 thus exhausting this benefit. 
 
 
Additionally, unlisted preventive dental service is not among those covered under this benefit. The Evidence of 
Coverage clearly states that any service not listed are not covered. Therefore, we decided that the Plan does not 
have to pay the in network rate for the limited oral evaluation (D0140) and the unlisted preventive dental 
service (D1999) provided from May 5, 2020, to May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth x-rays (D0210) provided on May 19, 2020. 
 
You asked the Plan to pay for the dental service. You say that you did not realize that this service was not 
covered. You also say that this is a really bad time to receive the bill. The Plan denied your request. The Plan 
says full mouth x-rays are not listed as a covered service. 
 
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 the full 
mouth x-rays (D0210) provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrotomy, including exploration, drainage, or removal 
of loose or foreign body (28022) provided on March 10, 2020 by the appealing provider. 
 
You asked the Plan to pay for the arthrotomy. You say that the services were provided and payment should be 
rendered. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 28022 is arthrotomy, including exploration, drainage, or 
removal of loose or foreign body. 
 
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 arthrotomy. Our reviewer says that the 
services are not supported. Our physician reviewer found the medical records provided does not include 
documentation of an Arthrotomy, including exploration, drainage, or removal of loose or foreign body; 
metatarsophalangeal joint being performed on March 10, 2020. 
 
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 arthrotomy have not been met. Therefore, we decided that the Plan does not 
have to pay for the arthrotomy, including exploration, drainage, or removal of loose or foreign body (28022) 
provided on March 10, 2020 by the appealing provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings (D0274) provided on June 9, 2020.You asked the Plan to pay forthe bitewings. You say that at the lecture regarding the benefits, you wrote down that a set of bitewings can be taken once a year.The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that you did not elect to purchase optional supplemental dental benefits.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 forthe bitewings (D0274) provided on June 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on June 11, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you believe a resin-based composite 
would be considered an additional service, which you have a $200 allowance for. The Plan denied your 
request. The Plan says you have exceeded the benefit period program maximum. 
 
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 Plan will cover up to $200 for any 
dental services that are not covered in the preventive services section of the EOC. The record shows that you 
met the annual maximum benefit while processing this claim for the June 11, 2020 date of service, and your 
$200 additional dental services benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) provided on June 10, 2020. You asked the Plan to pre-approve the comprehensive oral evaluation (D0150). You say that they would not agree to take care of the cavities until they completed their own evaluation. You say that payment should be considered. The Plan denied your request. The Plan says the comprehensive oral evaluation (D0150) 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 Plan also has a maximum benefit of one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation provided on November 1, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial 15 minutes of general sedation (D9222) and the 
additional 15 minutes of general sedation (D9223) provided on June 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the general anesthesia was necessary. The Plan 
denied your request. The Plan says general sedation is not listed as a covered service. The Plan also says any 
services not listed 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 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 the initial 
15 minutes of general sedation (D9222) and the additional 15 minutes of general sedation (D9223) provided on 
June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274) and panoramic x-ray (D0330) provided on May 14, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274) and 
panoramic x-ray (D0330). You say that the office didn't call to find out exactly what would be covered. You 
say that you cannot afford to pay for their mistake. The Plan denied your request. The Plan says the services 
exceeds the frequency limits set in the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one comprehensive oral evaluation every three plan years, one bite wing x-ray every plan year and one 
panoramic x-ray every three plan years. The Plan paid for a comprehensive oral evaluation provided on April 
25, 2019, bitewing x-rays provided on January 24, 2020 and a panoramic x-ray provided on March 15, 2019, 
which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150), bitewing x-rays (D0274) and panoramic x-ray (D0330) provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 11, 
2020 and billed under codes J3490, J3411, and J3415.  
 
You asked the Plan to pay for services rendered to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while code 97150 will be reprocessed, codes J3490, J3411 and J3415 
were not properly coded based on the units reported. The Plan says that only one unit is appropriate to bill for 
these codes. The Plan also notes that when these substances are mixed, they become a new substance. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. We find that the units billed for the codes in question are not supported in 
the limited medical records provided. Medicare rules for coverage of codes J3490, J3411 and J3415 are not 
met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
February 11, 2020 and billed under codes J3490, J3411, and J3415.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the COVID-19 cleanliness precautions 
(D1999) provided on May 21, 2020 by the out of network dental provider. 
 
You asked the Plan to pay the in network rate for the COVID-19 cleanliness precautions. You say that you 
broke your tooth while eating. You say that you only signed up for this plan in April. You also say that despite 
contacting the plan, you were never told that you needed to use a network provider. The Plan denied your 
request. The Plan says COVID-19 cleanliness precautions is not listed as a covered service. 
 
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 the in 
network rate for the COVID-19 cleanliness precautions (D1999) provided on May 21, 2020 by the out of 
network dental provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) and periodic oral evaluation 
(D0120) provided on June 23, 2020. 
 
You asked the Plan to pay more for the prophylaxis (D1110) and periodic oral evaluation (D0120). You say 
that you don't understand why you would be responsible for more than insurance paid. The Plan denied your 
request. The Plan says the claim 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the 
allowed amount for your covered dental services from an out-of-network provider. You are responsible for the 
remaining amount. Therefore, we decided that the Plan does not have to pay more for the prophylaxis (D1110) 
and periodic oral evaluation (D0120) provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7140) provided on June 17, 2020. 
 
You asked the Plan to pay for the dental service. You say that a piece of your tooth broke off leaving a sharp 
edge. You say that you could not chew, swallow, or talk without pain. You say that an x-ray showed that there 
was an infection. The Plan denied your request. The Plan says the extraction is not listed as a covered service. 
The Plan also says you were not enrolled in the optional supplemental dental rider at the time you received the 
service. 
 
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 the 
surgical extraction (D7140) provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings and unspecified preventive procedure provided 
on June 5, 2020, and June 8, 2020. 
 
You asked the Plan to pay for the bitewings and unspecified preventive procedure. You say that you have 
$1,000.00 per year for dental work. The Plan denied your request. The Plan says unspecified preventive 
procedure is not a covered benefit. The Plan also says that the benefits for the bitewing x-rays have been 
satisfied and the frequency limitation has been exceeded. 
 
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, unspecified preventive procedure is not 
among those covered under this benefit. The contract clearly states that bitewing x-rays are limited to one set 
per calendar year. The record shows that you received bitewings on March 4, 2020, and your bitewing x-rays 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings and 
unspecified preventive procedure provided on June 5, 2020, and June 8, 2020.