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

 
We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), 
periapical x-rays (D0220 x 2, D0230), bitewing x-rays (D0274), limited oral evaluation (D0140), and crown 
(D2740) provided from June 23, 2021, to October 14, 2021. 
You asked the Plan to reimburse you for the dental services. You say that you did not know that the provider 
did not accept Medicare until the claim denied. The Plan denied your request. The Plan says the provider in this 
case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have 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, services performed by a provider that 
has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), periapical x-rays (D0220 x 2, 
D0230), bitewing x-rays (D0274), limited oral evaluation (D0140), and crown (D2740) provided from June 23, 
2021, to October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on January 
27, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were having a problem in your vaginal 
area. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that the Plan reimbursed the services based on the 
Medicare allowed amount. A bill for assigned services is considered paid in full when the Medicare allowed 
amount is paid. Therefore, we decided that the Plan does not have to further pay for the evaluation and 
management services provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft  retained natural tooth  first 
site in quadrant (D4263). 
 
You asked the Plan to pre-approve bone replacement graft. You say that the enrollee has bone loss in teeth 7 
and 28 and requires this service. 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 pre-approve bone 
replacement graft  retained natural tooth  first site in quadrant (D4263).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95822) provided on March 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 95822 
is a column II code to column I code 51785. 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 the services (95822) provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult and tooth extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consult and tooth extraction. You say that you need to see an oral 
surgeon and do not have the money to pay for the services. The Plan denied your request. The Plan says the 
supplemental Dental Services benefit of your contract only provides coverage for dental services performed by 
a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consult and tooth extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260) provided by an out-of-network 
provider on December 15, 2021. 
 
You asked the Plan to pay for osseous surgery. You say that you had prior authorization for this. The Plan 
denied your request. The Plan says D4260 has been correctly denied. 
 
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 osseous 
surgery (D4260) provided by an out-of-network provider on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingevectomy/gingivoplasty (D4212) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that the service was necessary to secure your partial. 
You also say that you feel this service should be covered. The Plan denied your request. The Plan says 
gingevectomy/gingivoplasty is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingevectomy/gingivoplasty is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingevectomy/gingivoplasty (D4212) provided on December 9, 2021.
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 December 30, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe your plan 
covers two dental cleanings per year, and you scheduled 3 cleanings to take care of the issues you have. You 
also say that you would like this service to be covered because you had pain and believe the additional dental 
work you needed should be considered. 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 23, 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 December 30, 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 October 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that the provider was out of 
network. The Plan denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is listed as 
covered, dental services received out of network 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 October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve take home drugs (D9630). 
 
You asked the Plan to pre-approve take home drugs. You say that the service should be covered. The Plan 
denied your request. The Plan says take home drugs 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 take home drugs are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve take 
home drugs (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can get the care she needs at a lower level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 The enrollee is medically stable and does not need physical medicine and rehabilitation physician close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. There are no rehab nursing needs identified or documented in the record. At the 
current functional level, the enrollee does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management and the enrollee's rehab needs can be met in an alternate and lower setting. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental office wants to charge you $103 
without giving you any service. You say that you asked if they were going to pull your top teeth. You say that 
you were advised that they did not have time. You also say that you do not understand why they want to charge 
you. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system.

You asked the Plan to pre-approve the Volara system. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is specifically non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered.

We looked at the file and Medicare rules. In this case, the Volara system includes an IPV device. Based on this information, we decided that Medicare rules for coverage of the Volara system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven implant supported porcelain/ceramic crowns 
(D6065 x7). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crowns. You say that the dentist 
already started the treatment to help you with your dental problem, but the Plan is denying the remaining 
implants. 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 
seven implant supported porcelain/ceramic crowns (D6065 x7).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve blocks and 
injections (when block or injection is performed by a different provider); prone position 330 (01992) provided 
on April 2, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that please review and reprocess your claim for 
payment as you do have a qualifying diagnosis code on your claim that supports medical necessity for CPT 
code 01992. The Plan denied your request. The Plan says there were no doctor notes or operative notes given 
with the appeal to determine if the procedure and anesthesia was medically needed 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different provider); prone position 330 
(01992) provided on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), and to pay more 
for the periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 28, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, or pay more for the periodic oral evaluation, 
and prophylaxis. You say that when you called about your claim, you were not told that your dentist was OON. 
You also say that you have gone to this dentist your whole life, and your 2022 package says any OON dentist is 
covered at 100%. The Plan denied your request. The Plan says the first intraoral periapical x-ray is not a 
covered expense under your dental plan. The Plan 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. The Plan also says that you did not contact the Plan prior to 
the date of service to verify benefits and provider eligibility. 
 
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, first intraoral periapical x-ray (D0220) 
is not among those covered under this benefit. The contract also says that you are responsible for a 50% 
coinsurance for the periodic oral evaluation (D0120) and prophylaxis (D1110), plus the difference between the 
billed amount and allowed amount, because they were rendered by an OON provider. These services were 
rendered on December 28, 2021, before the 2022 plan benefit year began, and these services have been 
processed under your 2021 plan year benefits. Therefore, we decided that the Plan does not have to pay for the 
first intraoral periapical x-ray (D0220), and to pay more for the periodic oral evaluation (D0120), and 
prophylaxis (D1110) provided on December 28, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313) for a 
power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that the expandable controller was 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary.  
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 the expandable controller. Our reviewer 
says that the expandable controller is not medically necessary. Our physician reviewer found the enrollee has 
adequate upper extremity strength to operate the wheelchairs power options with their own switches. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve drugs dispensed for home use. You say that you would like this covered. 
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 pre-approve 
drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty (D4212). You say that you received this 
service due to the full partial and you did not want your gums to get infected. 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 
gingivectomy or gingivoplasty (D4212) provided on December 9, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care services (99223) provided on September 15, 
2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like this claim 
reprocessed based no the medical records. The Plan denied your request. The Plan says that this claim has been 
billed with an incorrect place of service codes based on where the enrollee was when the services were 
rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not sent any evidence that the enrollee was outpatient 
on the billed date of service. Something such as an emergency department or outpatient claim would be 
necessary. Therefore, we decided that the Plan has to pay for the initial hospital care services (99223) provided 
on September 15, 2021.  
 
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 the preventive procedure (D1999) provided on January 28, 2022. 
 
You asked the Plan to pay for the preventive procedure. The Plan denied your request. The Plan says this 
service code is not covered under your benefit package. 
 
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 
preventive procedure (D1999) provided on January 28, 2022.