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

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on October 18, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you 
were not advised that this provider withdrew from Medicare. You also say that it will be a hardship for you if 
you are not reimbursed. The Plan denied your request. The Plan says you received these services from a 
provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of 
Medicare effective March 3, 2021, to March 3, 2023. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays 
(D0274) provided on October 18, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) December 6, 2021. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that this service should be 
covered under either medical or dental. The Plan denied your request. The Plan says this service is not covered 
under your 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 the 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), and a 
resin-based composite (D2394) provided by a participating provider on October 1, 2021. 
 
You asked the Plan to pay for an intraoral periapical radiographic image and a resin-based composite. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered 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 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 an 
intraoral periapical radiographic image (D0220), and a resin-based composite (D2394) provided by a 
participating provider on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on November 11, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted the Plan benefit for this 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 
limited oral evaluation (D0140), provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate lower partial denture (D5222) provided on 
August 27, 2021. 
 
You asked the Plan to pay for the partial denture. You say that you should not be responsible for this bill. The 
Plan denied your request. The Plan says immediate lower partial denture 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, the immediate lower partial denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate lower partial denture (D5222) provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 22, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that it is vitally important that you receive at least three 
cleanings per year, and ideally four per year. The Plan denied your request. The Plan says this service exceeds 
the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, prophylaxes (D1110) are limited to 
two procedures per plan year. The record shows that you received prophylaxes (D1110) on April 26, 2021, and 
August 26, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis (D1110) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing radiographic images (D0274), periodic 
evaluation (D0120), and adjunctive pre-diagnostic (D0431), provided on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware the provider did not accept 
Medicare. The Plan denied your request. The Plan says you obtained services through a provider who has opted 
out of Medicare. 
 
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 bitewing radiographic images (D0274), periodic evaluation (D0120), and adjunctive pre-diagnostic (D0431), provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
limited oral evaluation - problem focused (D0140), and core buildup, including any pins when required 
(D2950) provided November 18, 2021. 
 
You asked the Plan to pay for the intraoral x-ray, limited oral exam and core buildup. You say that you were 
told this provider was in the Plan's network. The Plan denied your request. The Plan says the services have 
been reprocessed according to your in-network benefits. You have exceeded the frequency limit for the limited 
oral exam and the intraoral x-ray, and the core buildup is not a covered service under your 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 Plan covers the intraoral 
x-ray, limited oral exam and core buildup when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an intraoral x-ray and 
limited oral exam were provided October 2, 2021, and another limited oral exam was provided December 3, 
2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-ray 
and limited oral exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare 
coverage, the core buildup is not among those covered services. Therefore, we decided that the Plan does not 
have to pay for the intraoral - periapical first radiographic image (D0220), limited oral evaluation - problem 
focused (D0140), and core buildup, including any pins when required (D2950) provided November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on June 28, 2021. 
 
You asked the Plan to pay for the service provided. You say that routine drug testing is needed to monitor 
possible opioid abuse. The Plan denied your request. The Plan says the code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We looked at the file and the rules. Validity testing on urine specimens used for drug testing shall not 
separately bill the validity testing. Based on this information, we decided that Medicare rules for coverage of 
the service provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
service provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), and the surgical removal 
of implant body (D6100) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an endosteal implant and the surgical removal of implant body. You say that 
you are not working, and you cannot afford to pay for this dental work. The Plan denied your request. The Plan 
says the requested 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 pre-approve an 
endosteal implant (D6010), and the surgical removal of implant body (D6100) to be provided by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), and placement of intra-socket 
biological dressing to aid in hemostasis (D7922) provided on December 30, 2020. 
 
You asked the Plan to pay for the consultation and biological dressing. You say that you were given providers 
from the health plan. You also say that you did not go in the office asking which provider accepted your plan. 
The Plan denied your request. The Plan says the services you received are not listed as covered dental services. 
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 consultation and biological 
dressing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the consultation (D9310), and placement of intra-socket biological dressing to aid in hemostasis 
(D7922) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown to be provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that you would like the Plan to approve this. The Plan 
denied your request. The Plan says the benefit limit for a crown 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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a crown has already been 
provided one February 9, 2022. Based on this information, we decided that the Plan's rules for coverage of a 
crown have already been met. Therefore, we decided that the Plan does not have to pre-approve a crown to be 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth - partially bony (D7230) and 
deep sedation/general anesthesia - each subsequent 15-minute increment (D9223) provided September 20, 2021. 
 
You asked the Plan to pay for the removal of an impacted tooth and additional 15 minutes of general 
anesthesia. You say that you were misinformed about your dental benefits. The Plan denied your request. The 
Plan says you have exceeded the frequency limit for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the removal 
of one impacted tooth-partially boney and one additional 15 minutes of general anesthesia per year. 
We looked at the file and Medicare rules. The Plan provided documentation showing that one removal of an 
impacted tooth-partially boney and one additional 15 minutes of general anesthesia were covered on the same 
date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the 
removal of an impacted tooth and additional 15 minutes of general anesthesia has been exceeded. Therefore, 
we decided that the Plan does not have to pay for the removal of impacted tooth - partially bony (D7230) and 
deep sedation/general anesthesia - each subsequent 15-minute increment (D9223) provided September 20, 2021.  
 
Your complaint about potentially receiving incorrect, incomplete or confusing information from a plan 
representative or provider is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213), and a mandibular 
partial denture (D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a partial maxillary denture and a mandibular partial denture. You say that 
you need new dentures from a new dentist. You say that your current dentures do not fit correctly. The Plan 
denied your request. The Plan says the benefit limit for D5213 and D5214 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. The Plan covers a partial 
maxillary denture and a mandibular partial denture once every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D5213 and D5214 were 
provided on February 27, 2020. Based on this information, we decided that the Plan's rules for coverage of a 
partial maxillary denture and a mandibular partial denture have already been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial maxillary denture (D5213), and a mandibular partial denture 
(D5214) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this 
service to be paid from the medical portion of your account. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on March 8, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you have been having a hard time chewing. 
You also say that having partial denture would help with this. The Plan denied your request. The Plan says 
partial lower denture is not 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, the requested partial denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950), and a crown (D2740). 
 
You asked the Plan to pre-approve a core buildup and a crown. You say that you would like the Plan to 
approve this. The Plan denied your request. The Plan says the benefit limit for D2740 has already been 
exhausted. The Plan says that D2950 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. The Plan covers a crown once 
a year. The Plan does not cover a core buildup. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2740 was provided on January 
25, 2022. Based on this information, we decided that the Plan's rules for coverage a crown have already been 
met. D2950 is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a core 
buildup (D2950), and a crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on August 25, 2021. 
 
You asked the Plan to pay for code 83789. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated 
is not separately billable. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) provided 
on June 29, 2021. 
 
You asked the Plan to pay for ambulance supplies. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that they have agreed to cover the transport services (A0428, A0425) 
but the oxygen and oxygen supplies billed are included in these services and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that patient care equipment and first aid supplies 
provided during emergency ambulance transportation are all considered part of the general ambulance service 
and payment for them is included in the payment rate for the transport. 
 
We looked at the file and Medicare rules. Code A0422 is not eligible for separate payment. Based on this 
information, we decided that Medicare rules for coverage of ambulance supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies (A0422) provided on 
June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve a complete mandibular denture. You say that these dentures are medically 
necessary. The Plan denied your request. The Plan says D5120 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 pre-approve a 
complete mandibular denture (D5120) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panel testing provided on June 22, 2021. 
 
You asked the Plan to pay for panel testing. You say that the ordering physician regarded this testing as 
medically necessary. The Plan denied your request. The Plan says the denial of payment for these tests is 
correct, because two or more genes assayed in parallel constitute a single procedure service and require one 
procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of panel testing have not been met. Therefore, we decided that the Plan does not have to pay for panel 
testing provided on June 22, 2021.