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

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
fluoride varnish (D1208), adjunctive pre-diagnostic test (D0431), prefabricated post and core (D2954), and a 
crown (D2740) provided by an out-of-network provider on December 20, 2021, to February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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 (D0120), prophylaxis (D1110), fluoride varnish (D1208), adjunctive pre-
diagnostic test (D0431), prefabricated post and core (D2954), and a crown (D2740) provided by an out-of-
network provider on December 20, 2021, to February 7, 2022.
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 
April 26, 2022, to May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 April 26, 2022, to May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 26, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an
incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that the POS code must reflect the location in which
the services were rendered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Specifically, this claim was billed with POS code 31, which is
incorrect as the enrollee was not an inpatient in the skilled nursing facility when the services were provided.
The records do not support that the sample was taken in a laboratory setting.

Therefore, we decided that the Plan does not have to pay for the services provided on September 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported crowns on tooth #11 and 13 (D6068) 
provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered. The Plan denied 
your request. The Plan says abutment supported crowns (D6068) are not covered by your routine 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 abutment 
supported crowns on tooth #11 and 13 (D6068) provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two bone replacement grafts (D4263 x2). 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that you need this service because 
every time you brush your teeth you bleed a lot. The Plan denied your request. The Plan says this service is not 
covered under 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, 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 two 
bone replacement grafts (D4263 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you need these prostheses because you 
have no teeth. You also say that you can barely eat solid food because you cannot chew it properly. The Plan 
denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service January 19, 2021. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve a custom fabricated abutment and abutment supported crown. The Plan 
denied your request. The Plan says these services are not covered under 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, 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 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) and two retainer crowns (D6740 x2) 
provided on June 21, 2022. 
 
You asked the Plan to pay for the bridge. You say that you were advised that crowns were covered, and do not 
feel you should have to pay out of pocket. The Plan denied your request. The Plan says these services are not 
covered under 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, 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 pontic (D6245) and two retainer crowns 
(D6740 x2) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the cone beam capture and interpretation (D0364), 
limited oral evaluation (D0140), intraoral periapical first radiographic image (D0220), and the endodontic 
therapy, of a molar tooth (excluding final restoration) (D3330) provided on January 19, 2022 and February 16, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, the cone beam capture and interpretation service provided is not a covered benefit under 
your contractual policy.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
A $100 dental deductible was applied to the root canal therapy procedure provided on February 16, 2022.  
Additionally, the cone beam capture and interpretation service provided is not a covered benefit under your 
contractual policy. Therefore, we decided that the Plan does not have to pay more for the cone beam capture 
and interpretation (D0364), limited oral evaluation (D0140), intraoral periapical first radiographic image 
(D0220), and the endodontic therapy, of a molar tooth (excluding final restoration) (D3330) provided on 
January 19, 2022 and February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a direct placement of a restorative material to protect tooth (D2940) 
provided on June 16, 2022. 
 
You asked the Plan to pay for a direct placement of a restorative material to protect tooth (D2940). You say 
that this should be covered under the Plan. The Plan denied your request. The Plan says that this service is not 
covered under the 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. The Plan covers fillings. 
 
We looked at the file, and the Plan rules. The Plan contract states that they cover fillings. However, the Plan 
contract does not list specific codes that are not covered. The record shows that you received a filling. 
Therefore, we decided that the Plan has to pay for a direct placement of a restorative material to protect tooth 
(D2940) provided on June 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were charged for dentures that you never 
received, so you want your allowance back. 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 April 5, 2022. Therefore, 
we decided that the Plan has paid the full $1,500 dental benefit for dental services provided on April 5, 2022.
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 October 27, 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 performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on October 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision attachments on tooth #20 and 29 
(D6192). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says semi-precision attachments (D6192) are not covered by 
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 pre-approve 
semi-precision attachments on tooth #20 and 29 (D6192).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2021, billed with 
codes 81225, 81335, 81230, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says These services were not billed in 
accordance with Medicare rules. 
 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 
August 30, 2021, billed with codes 81225, 81335, 81230, 81241, 81291 and 81240.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453 and A4557 billed for date of service 
March 8, 2022. 
 
You asked the Plan to pay for procedure codes G0453 and A4557. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code G0453 is 
bundled into payment for code 95955. The Plan says that code A4557 is 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, we have confirmed that code G0453 
is a column II code to column I code 95955. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, we find that code A4557 has a status code of P under the Physicians Fee 
Schedule and no separate payment is made for this code under the fee schedule as payment is bundled into the 
payment for the services to which these codes are incident to. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes G0453 
and A4557 billed for date of service March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued acute inpatient hospital care provided from March 21, 2022, through April 12, 2022.

You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the continued acute inpatient hospital care provided was not medically necessary.


The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was admitted to the hospital on January 24, 2022 with sepsis, dehydration, and acute respiratory failure. She was treated and her condition stabilized and improved. She was considered medically stable for transfer to a skilled nursing facility. The documentation indicates that the enrollee did not require inpatient hospital care for the dates of service March 21, 2022, through April 12, 2022. The review has determined that the record showed that at the time of the inpatient admission the admitting physician did not reasonably expect that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the continued acute inpatient hospital care provided from March 21, 2022, through April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the immediate upper denture (D5130), 
and extractions (D7140 x 4, D7210) provided from February 9, 2022, to March 22, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says your quarterly allowance 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 quarterly allowance was exhausted on date of service February 9, 2022. Therefore, we decided that 
the Plan does not have to pay an additional amount for the immediate upper denture (D5130), and extractions 
(D7140 x 4, D7210) provided from February 9, 2022, to March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image tooth #01 32 
(D0220) provided on April 15, 2021. 
 
You asked the Plan to pay for an intraoral - periapical first radiographic image tooth #01 32 (D0220). You say 
that the periodontal maintenance was denied due to no history of periodontal maintenance. You say that you 
have included information with history of your treatment.  The Plan denied your request. The Plan says an 
intraoral - periapical first radiographic image tooth #01 32 (D0220) is not a covered service under your dental 
plan under any circumstances.  Periodontal maintenance (D4910) tooth #01 32 (D4910) for date of service 
April 15, 2021 was sent for reprocessing as this is 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 item intraoral - periapical 
first radiographic image tooth #01 32 (D0220) among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for an intraoral - periapical first radiographic image tooth #01 32 (D0220) 
provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Crown - porcelain fused to noble metal (D2752)-
Tooth #3. 
 
You asked the Plan to pre-approve a Crown - porcelain fused to noble metal (D2752)-Tooth #3. You say that a 
Crown - porcelain fused to noble metal, Tooth #3 is medically necessary. The Plan denied your request. The 
Plan says the tooth has too little bone in the middle roots to be allowed for dental coverage. 
 
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.  
 
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 a Crown - porcelain fused to noble 
metal (D2752)-Tooth #3. Our reviewer says that a Crown - porcelain fused to noble metal (D2752)-Tooth #3 is 
not medically necessary. Our physician reviewer found that due to the lack of adequate documentation, the 
criteria for coverage for a crown restoration for tooth #3 have not been met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a Crown - porcelain fused to noble metal (D2752)-Tooth #3. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Crown - porcelain fused to noble metal 
(D2752)-Tooth #3.