Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 2,
2022.
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on July 18, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test (D0431). You say that you believe this service 
should be covered under your supplemental benefits. The Plan denied your request. The Plan says this service 
is not covered under the benefit package. 
 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 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the porcelain/ceramic crown (D2740) provided on June 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should be covered for the crown. The 
Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the dental services by a contract provider. The file does not show that the Plan provided 
notice that this type of crown would not be covered. Under Medicare rules, this means this crown is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay 50% of the allowed amount of the 
porcelain/ceramic crown (D2740) provided on June 28, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from January 10, 2020, to February 13, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the skilled nursing facility (SNF) documentation requirement remains unmet for this encounter.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of the services have been met. The
provider did not include enough information to verify the skilled nursing facility (SNF) services in this case.
The Minimum Data Set (MDS) assessment, which is required documentation, was not included. Therefore, we
decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee
from January 10, 2020, to February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on July 21, 2022. 
 
You asked the Plan to pay for the crown. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall within 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 pay for a crown 
(D2740) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the medical criteria for D5225 have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maxillary 
partial denture when the services are medically necessary and reasonable.  
 
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 maxillary partial denture. Our 
physician reviewer found the medical criteria for D5225 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 maxillary partial denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a maxillary partial denture (D5225) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on June 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says the remaining five therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the medical records do not include current functional status or 
response to prior episodes of 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulpal debridement (D3221) for tooth #9 and #10. 
 
You asked the Plan to pre-approve the dental service. You say that you have a bad gum infection, and you need 
oral surgery for the gum infection. The Plan denied your request. The Plan says this service is covered in the 
root canal treatment of these teeth. The documentation shows periapical abscess associate with teeth #9 and 
#10 which have had inadequate root canal treatments. Part of the retreatment of the root canals in teeth #9 and 
#10 is the canal debridement (removal of canal filling and necrotic tissue). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says 
that separating the retreatment into two procedures (D3221 and D3346) is not medically reasonable. Our 
physician reviewer found that the documentation does not support the service of pulpal debridement when the 
root canal treatments for teeth #9 and #10 are covered. 
 
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 the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the pulpal debridement (D3221) for tooth #9 and #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dental services (D2950, D6240, D6750) 
provided on June 15, 2022 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 
covered with a copayment. 
 
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 a 
copayment for dental services.  
 
You have been asked to pay a $4,030 copayment for the dental services. This item/service falls within the 
Dental services benefit category. 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 waive the copayment for dental services (D2950, D6240, 
D6750) provided on June 15, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, intaoral x-ray, limited oral evaluation, 
and cone beam CT scan (D0140, D0220, D0364, D3320) provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and the charges would cause financial hardship. The Plan denied your request. The Plan says 
your benefit for the requested items or services (D0140, D0220, D3320) has already been exhausted and 
coverage for cone beam ct scans (D0364) is denied as this procedure is excluded from your 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. 
 
 
  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 January 4, 2022. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy, intaoral x-ray, limited oral 
evaluation, and cone beam CT scan (D0140, D0220, D0364, D3320) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) and the endodontic therapy 
(D3310) for tooth #11. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get 
these dental procedures done. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the core buildup and the endodontic therapy are not covered by 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. 
 
  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 the 
core buildup (D2950) and the endodontic therapy (D3310) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that there are no in-network providers in your 
area. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental benefits. Also, the Plan verified there are multiple in-network provider in the 
enrollee's area that are accepting new patients. 
 
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 are requesting 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 pre-approve an office 
visit with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling (D2335) on tooth #25. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to see a different dentist to 
fix the filling. 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 August 23, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a filling (D2335) on tooth #25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to see the out-of-network 
provider. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve the dental 
services with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2740), the core buildup (D2950), the 
prefabricated post for crown (D2954), and the endontic therapy (D3310) for tooth #23, #25, and #26. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because crowns, the core buildup, the prefabricated post for crown, and the endontic therapy are not covered by 
the Plan and dental services are only covered when done by an in-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. 
 
  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. Also, the requested dental services are from an out-of-network 
provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plans dental benefits are 
not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the 
Plan does not have to pre-approve the crowns (D2740), the core buildup (D2950), the prefabricated post for 
crown (D2954), and the endontic therapy (D3310) for tooth #23, #25, and #26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for traditional diagnostic fistula gram with assessment of the 
circuit from arterial anastomosis through the vena cava (36901) transluminal balloon angioplasty, central 
dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and 
interpretation required to perform the angioplasty. (List separately in addition to code for primary procedure.) 
(36907) provided April 22, 2022. 
 
You asked the Plan to pay for the diagnostic procedures. You say that please note procedure codes 36901 and 
36907 was not bundled with any other procedure code performed on the same date of service. Review the 
medical records and reprocess the claim for payment. The Plan denied your request. The Plan says add on code 
without appropriate primary procedure. Service included in global package. 
 
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 36907 is an add-on code and has not been billed with an appropriate 
primary procedure code. Procedure 36901 billed on date of service April 22, 2022, is included within the global 
surgery package of procedure 47490 billed on date of service April 13, 2022. This is a minor procedure that has 
a global surgery period of 10 days. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for traditional diagnostic fistula gram with assessment 
of the circuit from arterial anastomosis through the vena cava (36901) transluminal balloon angioplasty, central 
dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and 
interpretation required to perform the angioplasty. (List separately in addition to code for primary procedure.) 
(36907) provided April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4341), a partial maxillary denture (D5211), and a partial mandibular denture (D5212). 
 
You asked the Plan to pre-approve periodontal scaling and dentures. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says the requested items and 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 
periodontal scaling and root planing in all four quadrants (D4341), a partial maxillary denture (D5211), and a 
partial mandibular denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an endosteal implant for tooth 
numbers 4, 7, 8, 9, 10 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat and only have one tooth on 
your left side. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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 
surgical placement of an endosteal implant for tooth numbers 4, 7, 8, 9, 10 and 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment includes placement and 
abutment supported crown provided on February 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that this implant was the only option to replace the 
infected tooth. 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. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment includes placement and abutment supported crown provided on February 3, 2022.