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

 
We decided that the Plan does not have to pay for the emergency room visit (99284), and self-administered 
drugs (A9270) provided in an outpatient setting on August 1, 2021. 
 
You asked the Plan to pay for the emergency room visit and self-administered drugs. You say that your 
representative advised that all of your lab work in the hospital would be no charge. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, you have been asked to pay a $90 copayment for emergency services. 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 emergency room visit (99284), and self-administered drugs (A9270) 
provided in an outpatient setting on August 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided November 4, 2021. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that you feel this should be 
covered under your medical benefits because it is related to an injury from a fall. The Plan denied your request. 
The Plan says these are dental services which are not covered under 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 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 
limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
provided November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement grafts (D7953) for teeth # 24 and 26. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services to be covered. The 
Plan denied your request. The Plan says bone replacement graft is not 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 requested bone replacement grafts 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a bone replacement grafts (D7953) for teeth # 24 and 26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 19, 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 are not covered. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used. 
We looked at the file and Medicare rules. Billed procedure code 84480 is a column II code with a modifier 
indicator of 0 when billed with column I code 84481. Codes 84436 and 84479 are column II codes with a 
modifier indicator of 0 when billed with column I code 84439. The column II codes are not covered. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that definitive dug testing was provided. Providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
November 9, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. 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 June 1, 2023. Therefore, we decided that the Plan does not have to 
pay for dental services provided by an opt-out provider on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing radiographic images (x-ray) (D0274), provided 
on November 3, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the service should be covered. The Plan denied 
your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been 
exceeded. 
 
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 
bitewing radiographic images (x-ray) (D0274), provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the complete lower denture. We decided that the Plan does not have to 
pay for the complete upper denture.  
You asked the Plan to pay for the complete upper and lower dentures. You say that the lady at the office 
advised you could get dentures. You say that there was no mention of the cost of a lower out of pocket was 
mentioned. You also say that you are still wearing your old lower dentures. The Plan denied your request. The 
Plan says the claim denied correctly. 
 
We decided that the Plan has to pay for the complete lower denture.  
 
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. Specifically, there is no documentation to substantiate that the frequency limit 
has been reached. Therefore, we decided that the Plan has to pay for the complete lower denture.  
 
We also decided that the Plan does not have to pay for the complete upper denture. 
 
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 dentures are listed as covered, the 
frequency limit of 1 upper denture very 5 years has been exceeded. The record shows that the Plan paid for a 
complete upper denture that you received on March 28, 2019.  Therefore, we decided that the Plan does not 
have to pay for the complete upper denture. 
 
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 pre-approve bone replacement graft (D7953), guided tissue 
regeneration (D4266), and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the requested dental 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone replacement graft, 
guided tissue regeneration, and gingival irrigation are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pre-approve bone replacement graft (D7953), guided tissue 
regeneration (D4266), and gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on November 22, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe it had 
been 11 months since your last dental cleaning. The Plan denied your request. The Plan says these procedures 
are contract benefits once in a calendar year. 
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, evaluations and cleanings are each 
limited to one per calendar year. The record shows that you received a periodic oral evaluation (D0120) and 
prophylaxis (D1110) on January 28, 2021 and your evaluation and cleanings benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on November 22, 2021.  
 
Your complaint about your disappointment in the Plan's coverage is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057), and abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that when you signed up for this plan, you 
asked for dental coverage information. You say that you were advised crowns were covered at 50% of the 
allowed amount. You also say that you feel it was not disclosed that it had to be specific procedure codes only. 
The Plan denied your request. The Plan says the requested dental services are not listed as 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 custom fabricated 
abutment and abutment supported crown are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve custom fabricated abutment (D6057), and abutment 
supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve a custom fabricated abutment. You say that the requested services are 
necessary. The Plan denied your request. The Plan says a custom fabricated abutment is not 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 requested custom fabricated abutment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057).
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 additional 
intraoral periapical x-ray (D0230) provided on November 11, 2021. 
You asked the Plan to pay for the intraoral periapical x-rays. The Plan denied your request. The Plan says these 
services are not covered expenses 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 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 first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (D6056) provided on July 20, 2021. 
 
You asked the Plan to pay for the prefabricated abutment. You say that you would like to appeal this service. 
The Plan denied your request. The Plan says this service is 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 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 
prefabricated abutment (D6056) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
you believe these dentures are medically necessary to treat your mouth condition, and dentures are a covered 
benefit. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per 
period. 
 
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, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received a maxillary partial denture (D5213) and mandibular partial denture (D5214) on August 13, 
2019 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) 
 
You asked the Plan to pre-approve a complete upper denture. You say that you need the dentures. The Plan 
denied your request. The Plan says you are not yet eligible for coverage of dentures. 
 
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. The Plan excludes coverage of 
dentures to replace a tooth or teeth extracted prior to your effective date unless you have been continuously 
covered under the Plan for more than 24 months.  
 
We looked at the file and Medicare rules. In this case the denture is requested to replace teeth that were missing 
prior to coverage under the Plan and you have not been covered for more than 24 months. Based on this 
information, we decided that the Plan's rules for coverage of a complete upper denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on 
August 4, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the service should be covered. 
The Plan denied your request. The Plan says you have exhausted the Plan benefit for this 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 requested items or services are not 
among those covered under this benefit. Specifically, records indicate you have already received this service 
within the last three years. This means you have exceeded the Plan's benefit and are responsible for the cost. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided August 23, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were unaware that the dentist 
does not accept Medicare. The Plan denied your request. The Plan says this service is not covered because the 
provider has 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. The Plan covers the 
periodontal maintenance when you see any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare.  
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) and the not medically necessary 
service (S9986) provided on November 9, 2021. 
 
You asked the Plan to pay for the not medically necessary service. You say that you were told this was a 
contracted provider and these services would be covered. The Plan denied your request. The Plan says they 
have agreed to cover the eye exam as a Medicare covered service; however, the eye refraction and the not 
medically necessary service are not covered by Medicare or by your vision benefit, as the provider is not part 
of the specified routine vision network, and the not medically necessary service is not a covered service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam with eye refraction per plan year when the services are 
received from a provider in the specified vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case may be part of the Plans medical network, 
but they are not part of the Plans specified routine vision vendor network. Routine vision services are only 
covered when they are received from a provider in the specified network. In addition, the covered routine 
vision services include only a routine vision/eye exam and eye refraction. Based on this information, we 
decided that the Plan's rules for coverage of the not medically necessary service have not been met. Therefore, 
we decided that the Plan does not have to pay for the eye refraction (92015) and the not medically necessary 
service (S9986) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on October 5, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says the drug testing has been paid; however, the 
specimen validity testing is not separately payable. 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the billed services represent specimen validity testing. 
Based on this information, we decided that Medicare rules for coverage of the unspecified mass spectrometry 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the unspecified mass 
spectrometry provided along with drug testing on October 5, 2021, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on October 20, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your dentist did not 
advise you of the total cost for these services which you are unable to pay. The Plan denied your request. The 
Plan says you have exceeded your maximum benefit. 
 
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 Plan offers a $3,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit, and the final payment was paid on September 2, 2021 and your annual maximum benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on October 20, 2021.