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

 
We decided that the Plan does not have to pay for the root canal (D3330), pulp vitality tests (D0460), limited 
exam (D0140), and intraoral x-ray (D0220) provided on October 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were urgent, and the closest in-
network provider was not near you at the time. The Plan denied your request. The Plan says the provider in this 
case does not participate in Original Medicare. You may see any licensed dental provider who participates in 
the Medicare program. These services are not eligible for payment. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's contract states that 
you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted 
out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive reimbursement. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from dental 
providers who do not participate in Original Medicare are not covered under this benefit. The provider in this 
case does not participate in Medicare. Based on this information, we decided that the Plan's rules for coverage 
of dental services are not met. Therefore, we decided that the Plan does not have to pay for the root canal 
(D3330), pulp vitality tests (D0460), limited exam (D0140), and intraoral x-ray (D0220) provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided on December 10, 2020. 
 
You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99100, which has a status indicator of 'B' on the CMS Physician Relative Value File and is always 
bundled into payment for other services not specified and no separate payment is made per Medicare. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, 
we decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that the welcome document that you got from the Plan says that crowns are covered. You also 
say that the Plan contract does not specifically say that when a crown is put on an abutment it is not covered. 
The Plan denied your request. The Plan says these services are 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 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 pre-approve a 
custom fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge comprised of porcelain/ceramic retainer 
crowns (D6740) and pontics (D6245) for teeth #22 to #28. 
 
You asked the Plan to pre-approve a fixed bridge. You say that these services are necessary, and you cannot see 
your grandchildren looking like this. The Plan denied your request. The Plan says fixed bridges are only 
covered to replace one missing anterior (front) tooth in a single arch. The request in this case is for a seven-unit 
bridge to replace four missing teeth. These services are not a covered benefit as requested, and these teeth 
could be replaced with a partial denture. The Plan also states that teeth #27 and #28 will require restorations 
with core buildups and crowns; however, the dental provider will need to resubmit a claim with the proper 
restorative crown codes. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a fixed bridge 
when the services are requested to replace a single missing front tooth per arch. This service will not be 
allowed if more than one tooth (excluding 3rd molars) is missing in the same arch. We looked at the file and the Plan's rules. This request is for a fixed dental bridge to replace more than one tooth. Based on this information, we decided that the Plan's rules for coverage of a fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a fixed bridge comprised of porcelain/ceramic retainer crowns (D6740) and pontics (D6245) for teeth #22 to #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the porcelain crown (D2740) provided on July 16, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that you should be reimbursed for this 
service. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the porcelain crown is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
porcelain crown (D2740) provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), provided on November 17, 2021. 
 
You asked the Plan to pay for the extraction. You say that the service should be covered. The Plan denied your 
request. The Plan says this service was obtained through a provider who has opted out of Medicare. 
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
extraction (D7210), provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft, first site in quadrant (D4263 x 
4), and bone replacement graft, each additional site in quadrant (D4264 x 28). 
 
You asked the Plan to pre-approve the dental services. You say that your mouth is destroyed. You say that you 
need the services to restore function of your mouth. You also say that you want to have a healthy mouth and 
avoid infections. The Plan denied your request. The Plan says bone replacement grafts are not covered services. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone replacement grafts 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve bone replacement graft, first site in quadrant (D4263 x 4), and bone replacement graft, each additional 
site in quadrant (D4264 x 28).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments  includes modification and 
placement (D6056) and abutment supported porcelain fused to metal crowns (predominantly base metal) 
(D6060). 
 
You asked the Plan to pre-approve prefabricated abutments and abutment supported crowns. You say that you 
would like these services covered. 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 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 
prefabricated abutments  includes modification and placement (D6056) and abutment supported porcelain 
fused to metal crowns (predominantly base metal) (D6060).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220), and limited oral evaluation - problem focused (D0140) provided 
June 22, 2021, and the implant maintenance procedures when prostheses are removed and reinserted, including 
cleansing of prostheses and abutments (D6080) and unspecified adjunctive procedure, by report (D9999) 
provided November 23, 2021. 
 
You asked the Plan to pay for the bitewing x-rays, intraoral x-ray, limited oral exam, implant maintenance 
procedures and unspecified adjunctive procedures. You say that you require specialized dental care and would 
like the services covered. The Plan denied your request. The Plan says these services are not covered because 
the provider has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the bitewing 
x-rays, intraoral x-ray, limited oral exam, implant maintenance procedures and unspecified adjunctive 
procedures when you see any licensed dental provider who accepts Medicare patients in the United States and 
has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the bitewing x-rays, intraoral x-ray, limited oral exam, implant 
maintenance procedures and unspecified adjunctive procedures have not been met. Therefore, we decided that 
the Plan does not have to pay for the bitewings - four radiographic images (D0274), intraoral - periapical first 
radiographic image (D0220), and limited oral evaluation - problem focused (D0140) provided June 22, 2021, 
and the implant maintenance procedures when prostheses are removed and reinserted, including cleansing of 
prostheses and abutments (D6080) and unspecified adjunctive procedure, by report (D9999) provided 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve a complete mandibular denture. You say that your current dentures do not 
fit right. The Plan denied your request. The Plan says the benefit limit for D5120 has already been 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. The Plan covers one complete 
mandibular denture to be provided every five years.   
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete mandibular denture have already been met. Therefore, we decided that the Plan does 
not have to pre-approve a complete mandibular denture (D5120) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the core buildups, including any pins 
when required (D2950) provided December 13, 2021. 
 
You asked the Plan to provide additional payment for the core buildups. You say that you cannot locate any 
other dental claims submitted for the year 2021 and the full $1000 dental benefit should be available to use. 
The Plan denied your request. The Plan says your calendar year dental maximum has been met and no 
additional payment is due. 
 
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 core 
buildups up to the $1,000 supplemental annual dental maximum. 
 We looked at the file and Medicare rules. The Plan provided documentation showing that $356 was applied to 
your dental maximum on January 7, 2021, and $324 was applied to your dental maximum on November 23, 
2021. This means you had $320 remining in your dental allowance at the time of the services provided 
December 13, 2021. This remaining amount was applied to your December 13, 2021, claim. Based on this 
information, we decided that the Plan has processed your claim correctly. Therefore, we decided that the Plan 
does not have to provide additional payment for the core buildups, including any pins when required (D2950) 
provided December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two pontics (D6245 x2) and four crowns (D2740 x4) 
provided from May 27, 2021, to June 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pontics and crowns. You say that during the original date of service, April 
16, 2021, you were quarantined in Mexico, needed emergency dental work, and could not return to the United 
States for an in-network dentist. You also say that you hope this appeal will be considered because you are on a 
fixed income. The Plan denied your request. The Plan says the pontics are not a covered expense under your 
dental plan. The Plan also says that services performed by an OON provider are not covered because your 
healthcare plan does not have OON 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, pontic (D6245) is not among those 
covered under this benefit. The contract also says 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 two 
pontics (D6245 x2) and four crowns (D2740 x4) provided from May 27, 2021, to June 10, 2021 by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes 
(99239) provided on June 22, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that these services were billed 
correctly. The Plan denied your request. The Plan says this service is not supported in the medical record. The 
submitted discharge summary report does not support hospital discharge day management of more than 30 
minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. 
Therefore, the billed service cannot be verified. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not note the amount of time that was spent providing this service on the date in question. Based on this information, we 
decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes 
(99239) provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dentures (D5110 and D5120), provided on November 15, 2021. 
 
You asked the Plan to pay for the dentures. You say that the service was medically necessary. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
dentures (D5110 and D5120), provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 15, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you don't understand why this service isn't 
covered. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) provided November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you have been using this 
dentist for 16 years. You say that you would like the Plan to approve this. The Plan denied your request. The 
Plan says comprehensive oral services 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 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 pre-approve a 
comprehensive oral evaluation (D0150) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on June 15, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
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 looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a 
single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the panel testing services provided on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head 
rendered on September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well.  
The provider submitted a claim for procedure codes 70544 (head MRA) and 70551 (brain stem magnetic 
resonance imaging). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I 
code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore, 
we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head 
rendered on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a prefabricated post and core (D2954) 
for tooth #32 provided by a participating provider on November 4, 2021. 
 
You asked the Plan to pay for a crown and a prefabricated post and core. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says the benefit limit for D2740 and D2954 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 Plan's coverage rules apply in this case. The Plan covers a crown and a 
prefabricated post and core once per tooth per lifetime. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2740 and D2954 for tooth #32 
was provided on July 28, 2020.  Based on this information, we decided that the Plan's rules for coverage of a crown and a prefabricated post and core have already been met. Therefore, we decided that the Plan does not have to pay for a crown (D2740), and a prefabricated post and core (D2954) provided by a participating provider on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332), and intraoral imaging 
(D0220 and D0230) provided by a participating provider on November 23, 2021. 
 
You asked the Plan to pay for a resin-based composite and intraoral imaging. You say that you would like the 
Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services 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 pay for a resin-based composite (D2332), and intraoral imaging (D0220 and D0230) provided by a participating provider on 
November 23, 2021.