Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity, below knee, total contact 
(CPT code L5637) and addition, endoskeletal system, below knee, alignable system (L5910). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says below-the-knee components (alignable system and total contact) exceed the enrollee's 
need and is reasonable and necessary for the approved replacement prosthesis. 
 
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 items. Our physician reviewer 
found the documentation does not indicate the enrollee requires the requested components. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition to lower extremity, below knee, total contact (CPT code L5637) and addition, 
endoskeletal system, below knee, alignable system (L5910).
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 June 30, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that when you signed up 
for this plan, the representative advised that everything was covered, and there would be no copays or fees for 
any services. The Plan denied your request. The Plan says this service is not a covered expense under your 
dental plan. The Plan also says when you contacted the Plan, limited oral evaluation was not discussed during 
the call. 
 
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 
problem focused limited oral evaluation (D0140) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the core buildup, including any pins when required 
(D2950) provided on June 30, 2022. 
 
You asked the Plan to pay more for the core buildup. You say that fillings are paid in full, with no copay under 
your plan. You also say that you did not give the provider permission to perform anything other than the filling. 
The Plan denied your request. The Plan says you are responsible for a 50% coinsurance for the core buildup 
according to your Evidence of 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, you are responsible for a 50% 
coinsurance for the core buildup, including any pins when required (D2950). Therefore, we decided that the 
Plan does not have to pay more for the core buildup, including any pins when required (D2950) provided on 
June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of intra-socket biological dressing (D7922) 
provided on July 21, 2022. 
 
You asked the Plan to pay for the placement of intra-socket biological dressing. You say that the socket kept it 
from getting infected, which could have led to a number of things. You also say that this was an emergency 
dental visit. The Plan denied your request. The Plan says this service is not a covered expense 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 pay for the 
placement of intra-socket biological dressing (D7922) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342), gingival 
irrigationper quadrant (D4921), the comprehensive oral evaluation (D0150), resin-based composite-three 
surfaces, anterior (D2332), and the resin-based composite-three surfaces, posterior (D2393) provided from 
August 9, 2022, through August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. Additionally, gingival irrigation 
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 Plans coverage rules apply in this case.  
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Additionally, gingival irrigation is not a covered service. Therefore, 
we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342), gingival 
irrigationper quadrant (D4921), the comprehensive oral evaluation (D0150), resin-based composite-three 
surfaces, anterior (D2332), and the resin-based composite-three surfaces, posterior (D2393) provided from 
August 9, 2022, through August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on July 9, 2022 
 
You asked the Plan to pay for the dental services. You say that you need to get a new plate on your tooth. The 
Plan denied your request. The Plan says your benefits for the requested services have 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 benefits for the requested services were exhausted on date of service October 4, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-
ray (D0330) provided on July 9, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown on tooth #31 (D2740) provided on April 1, 
2022. 
 
You asked the Plan to pay more for a crown. You say that you were told the provider was in-network. The Plan 
denied your request. The Plan says that your annual dental benefit 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. 
 
 
 The record shows your annual dental benefit has been exhausted. You have been asked to pay $1,280 for a 
crown. 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 more for a crown on tooth #31 (D2740) provided on April 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on July 11, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you should be refunded for the services. 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 pay for the core 
buildup, including any pins when required (D2950) provided on July 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the medical records should be reviewed, and 
the claim reconsidered. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and not separately payable. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #11 (D2950). 
 
You asked the Plan to pre-approve core build up. You say that this service is part of the crown procedure. The 
Plan denied your request. The Plan says core build up (D2950) is not covered by your supplemental 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 pre-approve core 
build up on tooth #11 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body: endosteal 
implant (D6010), collection and application of autologous blood concentrate product (D7921), and a sinus 
augmentation via a vertical approach (D7952). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. 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 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 a surgical placement 
of an implant body: endosteal implant (D6010), collection and application of autologous blood concentrate 
product (D7921), and a sinus augmentation via a vertical approach (D7952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
27, 2022. 
 
You asked the Plan to pay 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 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 7/21/2020. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two core buildups, including any pins when required 
(D2950 x2) provided on June 1, 2022. 
 
You asked the Plan to pay for the core buildups. You say that you need help paying for these services. The Plan 
denied your request. The Plan says this service is not covered under your plan. The Plan also says that you 
signed the financial agreement given to you by the provider, and therefore, you were aware you would be held 
liable if the service was not covered by 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. 
 
 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 two 
core buildups, including any pins when required (D2950 x2) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim caries arresting medicament application (D1354) 
provided by a participating provider on July 21, 2022. 
 
You asked the Plan to pay for an interim caries arresting medicament application. You say that you feel like 
you were lied to. The Plan denied your request. The Plan says the dental service provided 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 an interim 
caries arresting medicament application (D1354) provided by a participating provider on July 21, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 75726 and 75774. We decided that the Plan does not 
have to pay for procedure codes 36248 and 37247.  
 
You asked the Plan to pay for procedure codes 36248 and 37247. The Plan says that procedure codes 36248 
and 37247 were billed without an appropriate primary procedure code. 
 
We decided that the Plan has to pay for procedure codes 75726 and 75774.  
 
The plan has not provided a valid reason for why these codes were not reviewed or a valid rationale for why 
payment cannot be issued. It is the burden of the Health Plan to substantiate their decision with evidence. In 
this case, the decision has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for procedure codes 75726 and 75774.  
 
We also decided that the Plan does not have to pay for procedure codes 36248 and 37247. 
 
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 36248 
and code 37247 are add-on codes that have not been billed with an appropriate primary procedure code. 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 codes 36248 and 37247. 
 
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 custom fabricated abutment (D6057) and abutment 
supported porcelain fused to metal crown (D6059) provided on June 9, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal 
crown. You say that this should be covered as a medical claim because the dental problems are a result from a 
medical injury. The Plan denied your request. The Plan says basic and major dental services are not covered 
under your plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment 
(D6057) and abutment supported porcelain fused to metal crown (D6059) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on July 13, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you feel like this should be covered. The 
Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided by an out-of-network provider on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency. 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 the dental services provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture  cast metal framework with 
resin denture bases (D5213) and mandibular partial denture  cast metal framework with resin dentures bases 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services provided as soon 
as possible. 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. This benefit includes 
maxillary partial denture  cast metal framework with resin denture bases (D5213) and mandibular partial 
denture  cast metal framework with resin dentures bases (D5214) but is limited to one procedure every five 
plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested maxillary partial denture  cast metal framework with resin denture bases 
(D5213) and mandibular partial denture  cast metal framework with resin dentures bases (D5214) was 
exhausted on date of service August 2, 2019. Therefore, we decided that the Plan does not have to pre-approve 
maxillary partial denture  cast metal framework with resin denture bases (D5213) and mandibular partial 
denture  cast metal framework with resin dentures bases (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam, cleaning, and dental imaging provided on 
April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you confirmed prior to the appointment that the 
provider was in network and would like for the claim to be paid according to the information you were given. 
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. The records show that at the time of service, the provider 
was not participating with the Plan. Even though the provided became contracted later and added to the in-
network provider directory, on the date of service at issue, the provider was out-of-network. 
 
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 an oral exam, cleaning, and dental imaging provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown repair and filling (D2980, D2950) 
 
You asked the Plan to pre-approve the crown repair and filling. 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 pre-approve a 
crown repair and filling (D2980, D2950)