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

 
We decided that the Plan does not have to pay for pulpal debridement on tooth #22 (D3221) provided on 
September 23, 2021, and a fabricated post (D2952) provided on October 8, 2021.  
 
You asked the Plan to pay for pulpal debridement and fabricated post. You say that you were in severe pain and 
these services were an emergency. The Plan denied your request. The Plan says pulpal debridement (D3221) 
and a fabricated post and core (D2952) are 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 pay for pulpal 
debridement on tooth #22 (D3221) provided on September 23, 2021, and a fabricated post (D2952) provided 
on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite one surface, posterior (D2391) 
provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been using this provider for a long 
time. 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 item or service 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 resin-based composite one surface, posterior (D2391) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 21, 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 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 July 15, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the topical 
application of fluoride varnish (D1206), and an unspecified preventive procedure (D1999) provided on August 
5, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that you only wanted a 
cleaning. The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation 
(D0150) has already been exhausted and the topical application of fluoride varnish (D1206) and unspecified 
preventive procedure (D1999) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 3, 2022. Also, 
the topical application of fluoride varnish (D1206) and the unspecified preventive procedure (D1999) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), the topical application of fluoride varnish (D1206), and an unspecified 
preventive procedure (D1999) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you went to this same provider in 
February, and were not advised that the provider became OON before this appointment. The Plan denied your 
request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when 
your services are received from an out-of-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.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on August 23, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown porcelain/ceramic (D2740) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal the denial. The Plan 
denied your request. The Plan says that 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. 
 
The Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is covered under 
this benefit. Therefore, we decided that the Plan has to pay for the crown porcelain/ceramic (D2740) provided 
on July 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 15, 
2022.  You asked the Plan to pay for procedure code 99100. You say that you are appealing the claim with medical 
records to process the claim for payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sinus augmentation with bone or bone substitutes (D7951) 
provided by an out-of-network provider on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 non-Medicare covered preventive dental services and non-Medicare covered 
comprehensive dental services has already been exhausted. Therefore, we decided that the Plan does not have 
to pay for sinus augmentation with bone or bone substitutes (D7951) provided by an out-of-network provider 
on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 01, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab testing provided on February 01, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150),  cone beam computed tomography (CT) image capture with field of view of one full dental arch  
mandible (D0381),  cone beam CT image capture with field of view of one full dental arch  maxilla, with or 
without cranium (D0382), cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367),  panoramic radiographic image (D0330), intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia  each 
subsequent 15 minute increment (D9243), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), surgical placement of implant body: endosteal implant (D6010), or bone graft at time of implant placement (D6104) provided from 
April 7, 2022 to April 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. 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 comprehensive exam was exhausted on date of service April 7, 2022, and April 18, 
2022. The one beam CT scans, panoramic x-rays, IV sedation, extractions and  implant are not covered under 
your benefits. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - 
new or established patient (D0150),  cone beam computed tomography (CT) image capture with field of view 
of one full dental arch  mandible (D0381),  cone beam CT image capture with field of view of one full dental 
arch  maxilla, with or without cranium (D0382), cone beam CT capture and interpretation with field of view 
of both jaws; with or without cranium (D0367),  panoramic radiographic image (D0330), intravenous moderate 
(conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia 
 each subsequent 15 minute increment (D9243), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), surgical placement of 
implant body: endosteal implant (D6010), or bone graft at time of implant placement (D6104) provided from 
April 7, 2022 to April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from December 
13, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were told the bill would be 
processed differently so the copay would be $0. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $295 
copayment per day, days 1 to 5 for inpatient services ($295 x 5 days = $1475).  
 
You have been asked to pay a $1475 for an inpatient stay. This item/service falls within the inpatient 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 an inpatient stay provided from 
December 13, 2021, to December 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on April 26, 2022. 
 
You asked the Plan to pay for a complete maxillary denture. You say that you would like the Plan to pay for 
this. 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 
complete maxillary denture (D5110) provided by a participating provider on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve greater occipital nerve block (64450), brachial plexus 
nerve block (64415), femoral nerve block (64447), sciatic nerve block (64445), and other nerve block (64450). 
 
You asked the Plan to pre-approve the nerve blocks. You say that the enrollee has had lower EMG in the past 
that showed bilateral extremity neuropathy. You also say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 nerve blocks. Our reviewer says that 
the requested nerve blocks are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not contain sufficient information in the medical records 
submitted. Therefore, the reviewer found that the requested nerve blocks were not medically reasonable or necessary. 
 
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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve greater occipital nerve block (64450), brachial plexus nerve block (64415), femoral 
nerve block (64447), sciatic nerve block (64445), and other nerve block (64450).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that the services at issue have been billed 
correctly for payment. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service January 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp vitality tests (D0460), and cone beam CT capture 
and interpretation with limited field of view  less than one whole jaw (D0364). 
 
You asked the Plan to pre-approve the pulp vitality tests (D0460), and cone beam CT capture and interpretation 
with limited field of view  less than one whole jaw (D0364). You say that you cannot afford to pay for these 
services and you have daily pain. The Plan denied your request. The Plan says these services are 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 pre-approve pulp 
vitality tests (D0460), and cone beam CT capture and interpretation with limited field of view  less than one 
whole jaw (D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#11. 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary that the enrollee gets the 
dental procedures done. The Plan denied your request. The Plan says your benefit for the crown and core 
buildup 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 crown and core buildup was exhausted on the date of service of December 17, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) 
for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211). 
 
You asked the Plan to pre-approve the maxillary partial denture  resin base (including, retentive/clasping 
materials, rests, and teeth). You say that you were approved for a partial denture but when you tried them on it 
did not fit properly. You also say that the dentist agreed with you that you need a new partial denture. 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 pre-approve a 
maxillary partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) for tooth 
#7, #10, and #15. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary that you receive 
the requested dental services. The Plan denied your request. The Plan says the x-rays do not show the tooth had 
a previous attempt at extraction resulting in part of a root being left buried in bone. To remove the remaining 
root there must be a failed attempt by an initial provider and the procedure must include removal of bone. The 
Plan recommends a surgical extraction of an erupted tooth (D7210). 
 
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 
services 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 services. Our reviewer says 
that the requested services of residual root removal (D7250) are not properly coded and therefore not 
reasonable or necessary. Our physician reviewer found that where there is coronal structure remaining on a 
tooth to be extracted, the proper codes would be either (D7140) or (D7210). The code for residual roots is 
reserved for situations where a tooth is missing, and a root fragment remains under the bone. In this instance 
there is some coronal structure remaining above the bone, and the teeth may be removed either with elevation 
and a forceps or possibly may require some removal of bone. The code of (D7250) would not be applicable in 
this instance. 
 
In this instance there are 3 teeth that do not have a prior attempted extraction, leaving some structure above the 
level of the bone in each case. The extractions would be initial attempts, and not considered removal of residual 
roots. The proper codes would reflect either simple extraction or a surgical extraction. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the removal of residual tooth roots (D7250) for tooth #7, #10, and #15.