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

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and 
crown - porcelain/ceramic (D2740) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider oversized the crown five years ago. 
You say that the services are a medical necessity. The Plan denied your request. The Plan says your benefit for 
the requested item or service $4,000 dollar limit was 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. 
 
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 April 12, 2022.  
 
 The record shows your benefit for the requested item or service was exhausted by other services on April 12, 
2022, due to dates of service April 18, 2022, and April 27, 2022, processing before the claim for the services at 
issue. Therefore, we decided that the Plan does not have to pay for core buildup, including any pins when 
required (D2950), and crown - porcelain/ceramic (D2740) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth #1, 16, 17, and 32 (D7220) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the tooth removals. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the removal of an impacted tooth (D7220) is 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 
removal of impacted tooth #1, 16, 17, and 32 (D7220) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants provided by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that dentures do not work for you. You say that 
you need implants. The Plan denied your request. The Plan says dental implants 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 pre-approve 
dental implants provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and the topical application of fluoride 
(D1206) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110) and the topical application of fluoride (D1206) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core build up on tooth #15 (D2950) and a porcelain crown on 
tooth #15 (D2752). 
 
You asked the Plan to pre-approve core build up and a crown. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the tooth does not appear to have significant 
breakdown due to decay or trauma. 
 
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 core build up 
and a crown 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 core build up and a crown. Our 
reviewer says that the coverage criteria has been met. Our physician reviewer found that due to the extent of 
the present restoration, a core buildup (D2950) and crown restoration (D2752) are medically reasonable and 
necessary to provide adequate masticatory function and support to the weakened coronal structure. 
 
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 core build up and a crown have been met. Therefore, we decided that the Plan 
has to pre-approve core build up on tooth #15 (D2950) and a porcelain crown on tooth #15 (D2752).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have exhausted your 
2022 transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray billed for services provided on May 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
The file shows that an x-ray of the right foot was provided. We looked at the file and Medicare rules. The file 
includes evidence that CPT code 73630-26-RT was reimbursed by the Plan on June 16, 2022. A comparison of 
the two claims shows these are exact duplicates.  There is no evidence presented to support that the billed services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the x-ray billed for services provided on May 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you started with this plan because of the $2,500 
dental coverage and amount of percentage which covers dental work. The Plan denied your request. The Plan 
says the denial of payment for core buildup (D2950) is correct because 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 core 
buildup (D2950) provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator to be used for the treatment of 
COPD and OSAS/OHS. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity-
hypoventilation syndrome. The appropriate treatment is BiPAP. BiPAP can provide the AVAPS mode, and this 
has not been tried. It may take more than 1 night to correct the chronic CO2 retention. Medicare does not cover 
a home ventilator for the treatment of OHS, or when used as BiPAP. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 2 and 3 (D2740), 
and periodontal scaling and root planing - four or more teeth per quadrant (D4341). 
 
You asked the Plan to pre-approve a crown - porcelain/ceramic tooth #'s 2 and 3 (D2740), and periodontal 
scaling and root planing - four or more teeth per quadrant (D4341). You say that you and the member are 
wanting these services covered. The Plan denied your request. The Plan says there is no clinical evidence to 
support the medical necessity. 
 
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 crown - 
porcelain/ceramic tooth #'s 2 and 3 (D2740), and periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) 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 crown - porcelain/ceramic tooth #'s 2 
and 3 (D2740), and periodontal scaling and root planing - four or more teeth per quadrant (D4341). Our 
reviewer says that the periodontal charting and x-rays do not support that there are any involved teeth in the 
lower right quadrant, therefore the scaling would not be a necessary service. Our physician reviewer found 
tooth #3 has an inadequately sealed root canal system along with deep decay near the distal bone which cannot 
be clearly discerned with the provided x-rays. Tooth #2 has deep decay that appears to be near the pulp of the 
tooth as well as the mesial bone making proper crown preparation impossible. Crown lengthening for tooth #'s 
2 and 3, along with endodontic treatment will be necessary to restore these teeth, as they would not be 
restorable as they present due to the proximity to the crestal bone level and therefore not necessary at this time. 
 
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 crown - porcelain/ceramic tooth #'s 2 and 3 (D2740), and periodontal scaling 
and root planing - four or more teeth per quadrant (D4341) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 2 and 3 (D2740), and periodontal 
scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty - four or more 
contiguous teeth tooth #UR, UL, LL, LR (D4210), removal of impacted tooth - completely bony tooth #16 
(D7240), therapeutic parenteral drugs, two or more administrations (D9612). 
 
You asked the Plan to pre-approve dental services. You say that you need the dental work in order to have a 
better quality of life. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Gingivectomy or 
gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant (D4210), removal of 
impacted tooth - completely bony tooth (D7240), therapeutic parenteral drugs, two or more administrations 
(D9612) are not covered under the Plans dental benefits. 
 
  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 
gingivectomy or gingivoplasty - four or more contiguous teeth tooth #UR, UL, LL, LR (D4210), removal of 
impacted tooth - completely bony tooth #16 (D7240), therapeutic parenteral drugs, two or more administrations 
(D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 22, 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 services D5110 and D5120 are not covered under 
the members dental coverage under any circumstances, while service D0150 is a covered benefit, but the 
enrollee has exceeded limits set in the subscriber agreement. 
 
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 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing of up to 14 drugs represented by code G0481 
and testing of up to 21 drugs represented by code G0482. 
 
You asked the Plan to pre-approve codes G0481 and G0482. You say that the clinical information provided 
shows medical necessity for the tests in dispute. The Plan denied your request. The Plan says there is no 
unexpected screen test for drugs of abuse in the record to justify 3 exact amount tests over 2 days. The Plan 
says that the tests which remain in dispute are not needed to help guide the enrollee's care. 
 
The Plan follows Medicare rules. Medicare rules say that ongoing testing for patients on chronic opioid therapy 
is covered when medically reasonable and 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 codes G0481 and G0482. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the available clinical 
documentation does not sufficiently support that ongoing testing is medically reasonable and necessary based 
on the patient history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, 
self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or 
other clinician documented change in affect or behavioral pattern. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes G0481 and G0482 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve testing of up to 14 drugs represented by code G0481 and testing of up to 21 
drugs represented by code G0482.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from April 6, 2022, 
through May 25, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this provider is not eligible for 
payment according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a licensed marriage and family therapist dis on 
the list of individuals who are not eligible to enroll in Medicare. Based on this information, we decided that 
Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services provided from April 6, 2022, through May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of medication (D1354) for tooth #5 and #12 
provided on May 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental services should be covered as the 
provider was an in-network provider. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the application of medication 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 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 
application of medication (D1354) for tooth #5 and #12 provided on May 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 31, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is fundamental in guiding the 
enrollee's treatment. The Plan denied your request. The Plan says that the claim was billed with an inconsistent 
date of service. 
 
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 file shows that breast cancer index (BCI) test was provided. The Plan has not shown that the billed date of 
service was incorrect. The Plan has not shown that the specimen did not meet one of the exceptions outlined in 
Medicare rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the laboratory 
services provided on August 31, 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 a comprehensive periodontal evaluation and oral hygiene 
instructions (D0180, D1330) provided on June 13, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and oral hygiene instructions. 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 
comprehensive periodontal evaluation and oral hygiene instructions (D0180, D1330) provided on June 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) and a 
problem focused limited oral evaluation (D0140) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider failed to inform you the bone 
replacement was not covered, and you would be responsible for the charges. The Plan denied your request. The 
Plan says D7953 is not a covered service and your benefit for D0140 has 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, the bone replacement graft (D7953) is 
not among those covered under this benefit. Additionally, the record shows your benefit for the problem 
focused limited oral evaluation (D0140) was exhausted on date of service March 30, 2022. Therefore, we 
decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) and a 
problem focused limited oral evaluation (D0140) provided on May 12, 2022.