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

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), and prophylaxis (D1110) provided on March 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, and prophylaxis. You 
say that prior to signing up you contacted the Plan to verify if the treating provider was covered, and you were 
advised he was. You also say that you were told after you had your fillings done that the treating provider was 
not part of the program. The Plan denied your request. The Plan says services are to be performed by a 
contracted dentist. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), first intraoral periapical x-ray (D0220), and prophylaxis (D1110) provided on March 
8, 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 the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350), gingival irrigation - per quadrant (D4921), oral hygiene instructions (D1330), and 
unspecified periodontal procedure, by report (D4999) provided February 16, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographs, gingival irrigation, oral hygiene instructions and 
unspecified periodontal procedure. You say that you cannot afford the cost of the services. The Plan denied 
your request. The Plan says these services are 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 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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350), gingival irrigation - per quadrant 
(D4921), oral hygiene instructions (D1330), and unspecified periodontal procedure, by report (D4999) 
provided February 16, 2022.  
 
Your complaint about having trouble with the Plan satisfying your insurance needs 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 provide an in-network benefit exception to pay for a periodic oral 
examination, periodontal maintenance after therapy and topical fluoride varnish provided on January 11, 2022, 
and a limited oral exam and periapical first film provided on February 8, 2022. 
 
You asked the Plan to provide an in-network benefit exception to pay for a periodic oral examination, 
periodontal maintenance after therapy and topical fluoride varnish provided and a limited oral exam and 
periapical first film. You say that you are 86 years old and you do not drive on the freeways. You say that 
nearby in-network providers were not taking new patients, and you had no choice but to stay with your current 
dentist. The Plan denied your request. The Plan says the requested provider is not a network provider and the Plan 
includes dental benefits for services received outside of the 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. 
 
We looked at the file and the Plans rules. The Plan offers a dental benefit in excess of Medicare coverage, with 
in-network and out-of-network benefits. Therefore, we decided that the Plan does not have to provide an in-
network benefit exception to pay for a periodic oral examination, periodontal maintenance after therapy and 
topical fluoride varnish provided on January 11, 2022, and a limited oral exam and periapical first film 
provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental savings plan purchased June 29, 2021. 
 
You asked the Plan to pay for the dental savings plan. You say that your plan allots $575 for dental coverage. 
The Plan denied your request. The Plan says savings plans 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental savings plan is not a service 
and thus is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
dental savings plan purchased June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided January 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you would like these 
services covered. The Plan denied your request. The Plan says these services are not covered because they were 
provided OON. 
 
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 periodic 
oral exam and dental cleaning when the services are provided in-network.  
 
We looked at the file and Medicare rules. In this case the dental services were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the periodic oral exam and dental cleaning have 
not been met. 
 
 Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient 
(D0120) and prophylaxis - adult (D1110) provided January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for denosumab (Prolia, Xgeva) (J0897) 
provided February 23, 2022. 
 
You asked the Plan to waive the copayment for the Prolia injection. You say that you take this drub via 
injection twice a year and the Plan has always covered the entire cost of the injections. The Plan denied your 
request. The Plan says the claim was processed correctly per the Evidence of Coverage. 
 
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 20% 
coinsurance for all other drugs covered under Medicare Part B.  
 
You have been asked to pay $254.52 for the Prolia injection. The Prolia injection falls within the Medicare Part 
B prescription drugs 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 denosumab (Prolia, 
Xgeva) (J0897) provided February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Euflexxa injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a trial of the preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there is no 
indication of a trial and failure of the required drugs. Based on the medical records provide and the Medicare-
approved drug compendia, there is no indication that the plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Euflexxa injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the dental cleaning 
(D1110), and the intraoral-complete series of radiographic images (D0210) rendered by the out-of-network 
(OON) provider on January 31, 2022. 
 
You asked the Plan to pay for these 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 services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), the dental cleaning (D1110), and the 
intraoral-complete series of radiographic images (D0210) rendered by the out-of-network (OON) provider on 
January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and cone 
beam computed tomography (CT) capture and interpretation (D0367) provided on December 30, 2021 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and cone beam CT capture and 
interpretation. You say that you believe you are entitled to a $500 reimbursement due to your benefit plan. The 
Plan denied your request. The Plan says you received these services from a provider who chose not to receive 
Medicare funds. The Plan also says that this provider is on the Medicare opt out list. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and cone beam computed 
tomography (CT) capture and interpretation (D0367) provided on December 30, 2021 by a Medicare opt out 
provider.
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), 
comprehensive oral evaluation (D0150), intraoral periapical x-rays (D0220 and D0230), bitewing x-rays 
(D0274), crown (D2740), and periodontal maintenance (D4910) provided on March 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the core buildup, comprehensive oral evaluation, intraoral periapical x-rays, 
bitewing x-rays, crown, and periodontal maintenance. You say that you needed an emergency crown procedure 
because you had broken your rear molar. You also say that a Plan representative advised that this claim would 
be paid. The Plan denied your request. The Plan says the core buildup is not a covered expense under your 
dental plan. The Plan says that services performed by an OON provider are not covered because your 
healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the 
date of service to verify benefits and provider eligibility.  
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, core buildup, including any pins when 
required (D2950) is not among those covered under this benefit. The contract also clearly states that you are 
responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that 
the Plan does not have to pay for the core buildup, including any pins when required (D2950), comprehensive 
oral evaluation (D0150), intraoral periapical x-rays (D0220 and D0230), bitewing x-rays (D0274), crown 
(D2740), and periodontal maintenance (D4910) provided on March 22, 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 the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), and simple extractions (D7140) provided on January 31, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
simple extractions. The Plan denied your request. The Plan says your plan does not cover services from a 
provider who is not in-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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and simple extractions 
(D7140) provided on January 31, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
January 20, 2022. 
 
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says an anatomical modifier was not appended to the original claim, 
nor to the claim image attached to the appeal. 
 
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, the CPT Code Manual definition of code 73630 is "Radiologic examination, foot; complete, 
minimum of 3 views." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records include two 
identical radiology reports, shoulder left three views. A radiologic examination of the foot was found in the 
documentation.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on January 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you have been making progress in your 
physical therapy sessions, and it is necessary for you to continue this care. The Plan denied your request. The 
Plan says they agree that an additional ten (10) PT visits are medically reasonable and necessary; however, the 
additional two visits requested are not necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy and the documentation does not reveal that you require the unique skills of a professional 
therapist to safely and effectively provide treatment or that the services can only be safely and effectively 
performed by a therapist, or by or under the supervision of a therapist. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. You can transition to an independent home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve two (2) additional physical therapy (PT) visits.
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 March 10, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the treating provider 
needed to do a complete evaluation in order to fully understand the issues you were having at the time. The 
Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 24, 2022 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and the 
intraoral-complete series of radiographic images (D0210) provided on March 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency 
for these 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.  
 
We looked at this case file and the Plan's rules. Based on this information, we have decided that the services 
provided in this case do not meet the Plan's rules for coverage.  Specifically, the Plan covers a comprehensive 
oral examination and an intraoral-complete series of radiographic images once every three years. You 
previously received these services on February 12, 2020 that were paid for by the Plan. Therefore, you 
have exceeded the allowable benefit for these services. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral examination (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on February 22, 2022. 
 
You asked the Plan to waive the copayments for the periodic oral evaluation and prophylaxis. You say that 
when you were researching Plans in December 2021, you saw no information regarding copays for dental 
services under your plan. The Plan denied your request. The Plan says the $15.00 copay applied to each service 
(total of $30.00) is contractual according to terms listed in the 2022 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 $15 
copayment per service during the visit for covered routine dental services when provided by an in-network 
provider. Therefore, we decided that the Plan does not have to waive the copayments for the periodic oral 
evaluation (D0120) and prophylaxis (D1110) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid battery (V5266) provided on August 20, 2021. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered by Medicare.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code V5266 has a status indicator of N on the Physician Fee Schedule. This means that CPT 
code V5266 is a non-covered service by Medicare. These codes are carried on the Healthcare Common 
Procedures Coding System (HCPCS) as non-covered services. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Additionally, Plan has already paid more than the 
$2000 benefit for hearing aids. Therefore, we decided that the Plan does not have to pay for the hearing aid 
battery (V5266) provided on August 20, 2021.