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

 
We decided that the Plan does not have to pay for a resin-based composite - four or more surfaces or involving 
incisal angle (anterior) (D2335), and a limited oral evaluation - problem focused (D0140) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a tooth repaired due to an accident. 
You also say that it was a broken tooth so medical insurance should pay. The Plan denied your request. The 
Plan says your benefit for the resin-based composite has already been exhausted. The Plan also denied the 
limited oral evaluation - problem focused as it is not covered by the Plans 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, certain limitations apply. The record 
shows your benefit for a resin-based composite was exhausted on date of service April 1, 2022. The limited 
oral evaluation - problem focused is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for a resin-based composite - four or more surfaces or involving incisal angle 
(anterior) (D2335), and a limited oral evaluation - problem focused (D0140) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the intraoral 
radiographic images (D0210) provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should have checked to see what 
was covered and you would have denied the services if they were not covered. 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 items or services was exhausted on the date of service of November 22, 
2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
and the intraoral radiographic images (D0210) provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 05, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 12, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth was shattered due to a fall and you 
went to the dentist for an evaluation. You also say that the x-ray was needed to see if there was any trauma to 
the nerve. The Plan denied your request. The Plan says your benefit for the requested services 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 limited oral evaluation - problem focused was exhausted on date of service 
September 29, 2022, and the intraoral - periapical first radiographic image was exhausted on date of service 
March 28, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), and intraoral - periapical first radiographic image (D0220) provided on December 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x5 provided on 
September 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told the provider was in-network, but 
once you arrived for your appointment you told they office was out-of-network. The Plan denied your request. 
The Plan says this service is not covered under your 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. Extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7210 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) x5 provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310), and clinical crown 
lengthening (D4249), provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that there was an initial mix-up with your insurance. 
You say that this was corrected, and these services should be covered. The Plan denied your request. The Plan 
says these 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 
diagnostic service consultation (D9310), and clinical crown lengthening (D4249), provided on December 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 02, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral images 
(D0220), the root canal (D3330) provided by an out-of-network provider on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the provider the services 
would be covered in full and you did not know the provider was out-of-network. The Plan denied your request. 
The Plan says you are responsible for 50% of the approved services and any charged amount above the Plans 
cost-sharing amount when your services are received from an out-of-network provider. 
 
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 total allowed amount for the limited oral evaluation was $70 with a $35 coinsurance ($70 allowed amount 
x 50% of the allowed amount). The total allowed amount for the intraoral images was $24 with a $12 
coinsurance ($24 allowed amount x 50% of the allowed amount). The total allowed amount for the root canal 
was $925 with a $462.50 coinsurance ($925 allowed amount x 50% of the allowed amount). You have also 
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. Therefore, we decided 
that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral images (D0220), the 
root canal (D3330) provided by an out-of-network provider on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210), and a bone replacement graft 
(D7953), provided on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an injection, and you needed this dental 
work. 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 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 an 
extraction (D7210), and a bone replacement graft (D7953), provided on October 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an imaging of urinary tract following injection of a contrast agent 
provided on November 07, 2022, billed with procedure code 74420. 
 
You asked the Plan to pay for the retrograde urography. You say that this service was billed correctly. The Plan 
denied your request. The Plan says that the service was already paid on the same date of service on a different 
claim number for a different provider. 
 
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 74420 is urography, retrograde, with or without KUB. 
 
We find that CPT 74420 is supported in the record. Specifically, the documentation submitted clearly shows 
that this provider rendered the retrograde urography on the billed date of service. Additionally, the providers at 
issue in the Plans argument have different specialties and are not considered the same physician. Based on this 
information, we decided that Medicare rules for coverage of the retrograde urography have been met. 
Therefore, we decided that the Plan has to pay for an imaging of urinary tract following injection of a contrast 
agent provided on November 07, 2022, billed with procedure code 74420.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 30, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and the intraoral 
radiographic image (D0220) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the benefits limitations being 
exceeded because you get cleanings twice a year. The Plan denied your request. The Plan says your benefit for 
the requested items or services 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 intraoral radiographic image was exhausted on the date of service of January 31, 
2022, and your benefit for the periodic oral evaluation was exhausted on the date of service of June 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and the 
intraoral radiographic image (D0220) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you could see any provider, so 
you do not understand why payment is being denied. 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 on November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code B4034 billed for date of service October 9, 
2022 to November 6, 2022. 
 
You asked the Plan to pay for procedure code B4034. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code B4034 is 1. The MAI value for this code is 1. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code B4034 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code B4034 billed for date of service October 9, 2022 to November 6, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast ultrasound provided on June 15, 2022. 
 
You asked the Plan to pay for a breast ultrasound. You say that we rely on the hospital to obtain all necessary 
paper work including authorization numbers and referral forms. Please review and process claim for payment. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a breast ultrasound 
provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic office visits to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the chiropractic visits. You say that you do not agree with the denial of 
these services. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the chiropractic office visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft, guided tissue regeneration, 
nitrous oxide, surgical access to an implant body and surgical placement of implant body. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial for implants 
and these services are not cosmetic. The Plan denied your request. The Plan says these services are not covered 
by the Plan's 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. Additionally, dental implants are generally covered under your dental 
plan. The records show your provider has not provided the Plan with documentation required to perform 
implant treatment. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft, 
guided tissue regeneration, nitrous oxide, surgical access to an implant body and surgical placement of implant 
body.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service November 23, 
2022.