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

 
We decided that the Plan does not have to pre-approve gingival irrigation, per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you are asking the Plan to review and 
reconsider coverage. The Plan denied your request. The Plan says the requested service 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 
gingival irrigation, per quadrant (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement 
graft for ridge preservation (D7953), and comprehensive oral evaluation (D0150) provided on September 9, 
2021, and November 1, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft, and comprehensive oral 
evaluation. You say that you would like to know why some of the services were approved but others were not. 
The Plan denied your request. The Plan says the guided tissue regeneration and bone replacement graft are not 
covered benefits under your dental plan. The Plan also says that the comprehensive oral evaluation 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, the guided tissue regeneration (D4266) 
and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The 
contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. 
The record shows that you received a comprehensive oral evaluation (D0150) on November 5, 2020 and your 
comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the guided tissue regeneration (D4266), bone replacement graft for ridge preservation 
(D7953), and comprehensive oral evaluation (D0150) provided on September 9, 2021, and November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2), 
complete maxillary denture (D5110), mandibular immediate denture (D5140), and 9 simple extractions (D7140 
x9) provided on November 4, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedures, complete maxillary denture, 
mandibular immediate denture, and simple extractions. You say that you were told that you only needed to pay 
$1,150.00, but now you are being charged $1,999.00 more. You also say that you maxed out your care credit 
and credit card, and are on a fixed income. The Plan denied your request. The Plan says the removable 
prosthodontic procedures are not a covered expense under your dental plan. The Plan also says that these 
services were performed by a non-participating provider, and you are responsible for any difference between 
the Maximum Allowable Fee and the amount the provider bills you for the 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 unspecified removable 
prosthodontic procedure (D5899) is not among those covered under this benefit. You are also responsible for 
the difference between the billed amount and allowed amount for covered dental services that are received 
OON. Therefore, we decided that the Plan does not have to pay for the two removable prosthodontic 
procedures (D5899 x2), complete maxillary denture (D5110), mandibular immediate denture (D5140), and 9 
simple extractions (D7140 x9) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) and dental cleaning (D1110) 
provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not realize this provider was out-of-
network. The Plan denied your request. The Plan says the provider in this case is out-of-network. Non-network 
dentists have not agreed to provide services at contracted rates. If you see an out-of-network dentist, the 
coinsurance level will apply to the average negotiated in-network fee schedule in your area. You are 
responsible for the difference between this fee and what the out-of-network provider bills for covered dental 
services. In addition, the record shows that you did not contact the Plan to verify your benefits and provider 
eligibility prior to services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that 
you must pay 50% coinsurance for covered services performed by an out-of-network provider. Benefits 
received out-of-network are subject to any in-network benefit maximums, limitations and/or exclusions. You 
may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the 
provider. 
 
The provider billed the Plan a total of $164 for the dental cleaning and exam provided on November 24, 2021. 
The Plans allowed fee for these two services is $75. This is the amount an in-network provider would accept 
as full payment for these services; however, out-of-network providers do not have this agreement with the Plan 
and are allowed to bill you the difference between the full billed amount and the Plans rate ($164 - $75 = $89). 
In addition, you are responsible for 50% coinsurance on the Plans allowed rate for out-of-network services 
($75 x 50% coinsurance = $37.50). You have been asked to pay $126.50 for these services ($89 + $37.50 = 
$126.50). This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to pay for the periodic oral exam (D0120) and dental cleaning (D1110) 
provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010x2), a 
prefabricated abutment (D6056x2) and an implant supported porcelain/ceramic crown (D6065x2). 
 
You asked the Plan to pre-approve a surgical placement of an implant body, a prefabricated abutment and an 
implant supported porcelain/ceramic crown. You say that you do not agree with the denial. The Plan denied 
your request. The Plan says the requested 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 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 pre-approve a 
surgical placement of an implant body (D6010x2), a prefabricated abutment (D6056x2) and an implant 
supported porcelain/ceramic crown (D6065x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two 
implant supported crowns (D6066 x2). 
 
You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say 
that these services are necessary for your health and wellness. The Plan denied your request. The Plan says 
these services 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 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 
custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture (D5865). 
 
You asked the Plan to pre-approve overdenture. You say that you need the implants on the bottom. You also 
say that the services are necessary for you to be able to eat properly. The Plan denied your request. The Plan 
says overdenture 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 requested overdenture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve overdenture 
(D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751 x 2) and pontic (D6241). 
 
You asked the Plan to pre-approve a fixed bridge. You say that crowns are covered once every 5 years per 
tooth. The Plan denied your request. The Plan says fixed bridge is not a covered dental item. 
 
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 fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6751 x 2) and pontic (D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553).
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician as required per CMS guidelines. In addition, documentation submitted did not sufficiently support the billed supply code. Outreach was made to both the member and provider to confirm treatment history and validate the written order; however, all attempts were unsuccessful.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order and proof of delivery. There is no evidence the treating physical discussed the need of this item and the delivery slip was not both signed and dated by the member. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Additionally, the member is not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, and therefore, the item is not medically necessary. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an introduction of catheter (36010), venography (75822, 
75825), injection procedure for venography (36005), and ultrasound guidance for vascular access (76937) 
provided on August 24, 2021. 
 
You asked the Plan to pay for an introduction of catheter, venography, injection procedure for venography, and 
ultrasound guidance for vascular access. You say that you have provided records to support the level of service. 
The Plan denied your request. The Plan says the codes at issue are inclusive to other billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
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 an introduction of catheter and venography. 
Our reviewer says that codes 36010, 75822, and 75825 do not meet criteria for reimbursement. Our physician 
reviewer found that CPT code 36010 was reported with CPT code 37193. The operative report does not clearly 
document an introduction of catheter separate from retrieval of intravascular vena cava filter and therefore 
cannot be verified. CPT codes 75822 and 75825 were reported as distinct procedures from CPT code 37187. 
The operative report describes a thrombectomy, which would include radiological supervision in order to 
perform this procedure. The operative report does not describe a separate distinct procedure to support billing 
codes 75822 or 75825 with modifier -59. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an introduction of catheter and venography have not been met. 
 
We have confirmed that codes 36005 and 76937 are column II codes to column I code 37193. Codes 36005 and 
76937 have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met for an injection procedure for venography and ultrasound guidance 
for vascular access. Therefore, we decided that the Plan does not have to pay for an introduction of catheter 
(36010), venography (75822, 75825), injection procedure for venography (36005), and ultrasound guidance for 
vascular access (76937) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230), a 2D oral/facial imaging 
(D0350), a cone beam tomography capture (D0367), and a resin-based composite (D2330) provided by a 
participating provider on November 12, 2021. 
 
You asked the Plan to pay for intraoral imaging, a 2D oral/facial imaging, a cone beam tomography capture, 
and a resin-based composite. You say that these services should be covered because they are on the list. The 
Plan denied your request. The Plan says the services that were provided are 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 pay for intraoral imaging (D0230), a 2D oral/facial imaging (D0350), a cone beam tomography capture (D0367), and a resin-
based composite (D2330) provided by a participating provider on November 12, 2021.  
 
The comprehensive oral evaluation (D0150) and bitewings (D0274) that were provided are covered services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold pad with pump (E0218). 
 
You asked the Plan to pre-approve the cold pad with pump. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cold pad with pump have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230), 5 simple 
extractions (D7140 x5), complete maxillary denture (D5110), and complete mandibular denture (D5120) 
provided on May 27, 2021, and June 3, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray, 5 simple extractions, complete maxillary 
denture, and complete mandibular denture. You say that you had no choice but to go to this dentist because 
during COVID-19, no other dentist would take new patients. You also say that you would like to be paid what 
the Plan would have paid if the dentist you saw was in-network. The Plan denied your request. The Plan says 
the complete maxillary denture and complete mandibular denture are not covered expenses under your dental 
plan. The Plan also says that your benefits for the intraoral x-ray and 5 additional extractions have been 
satisfied and the frequency limitations have 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, the complete maxillary denture 
(D5110) and complete mandibular denture (D5120) are not among those covered under this benefit. The 
contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that 
you received a first intraoral periapical x-ray (D0220) on May 27, 2021 and your intraoral x-rays benefit has 
been exhausted. The Plan contract also says that extractions are limited to two procedure codes per calendar 
year. The record shows that you and 7 simple extractions (D7140 x7) on May 27, 2021, two of which were 
covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the additional intraoral periapical x-ray (D0230), 5 simple extractions (D7140 x5), complete 
maxillary denture (D5110), and complete mandibular denture (D5120) provided on May 27, 2021, and June 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opted-out provider on January 
11, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told that this provider was in-network. 
The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until July 15, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services coded 99100 provided on May 21, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the anesthesia services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have 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. 
 
Per the Physician Fee Schedule, CPT code 99100 has a status indicator of B. This means that the payment for 
99100 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that 
the Plan does not have to pay for anesthesia services coded 99100 provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigations (D4921) provided on November 2, 2021. 
 
You asked the Plan to pay for the gingival irrigations. You say that you had an emergency while eating and 
your top filling came out and sliced your tongue. The Plan denied your request. The Plan says 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 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 
gingival irrigations (D4921) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260). 
 
You asked the Plan to pre-approve the osseous surgery. You say that you do not have the financial resources to 
pay for this procedure. The Plan denied your request. The Plan says this procedure is not included in the 
benefits section of your 2021 and 2021 Evidence of Coverage's. 
 
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 
osseous surgery (D4260).