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

 
We decided that the Plan does not have to pre-approve a diagnostic cast (D0470), complete denture (D5110), 
partial denture (D5214), and occlusion analysis (D9950). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental services done because 
of the procedure you got last year. The Plan denied your request. The Plan says the denial of authorization for 
the diagnostic casts and occlusion analysis is correct, because these services are not covered by the Plan. Also, 
your benefit for the complete denture and partial denture 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 complete denture and partial denture was exhausted on date of service of March 24, 
2021, and diagnostic cast and occlusion analysis are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a diagnostic cast (D0470), complete denture (D5110), 
partial denture (D5214), and occlusion analysis (D9950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140, D7210), an upper partial denture 
(D5213), and bone replacement graft (D7953) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary, and you were not 
aware they wouldn't be covered. The Plan denied your request. The Plan says your benefit for the extractions 
and the upper partial denture 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 benefit for the upper partial denture was exhausted on date of service December 19, 2019, and your 
benefit for the extractions was exhausted on date of service May 4, 2022. Additionally, bone grafts are not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for extractions (D7140, D7210), an 
upper partial denture (D5213), and bone replacement graft (D7953) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a 
participating provider on May 23, 2022. 
 
You asked the Plan to pay for a crown (D2740) and a core build-up (D2950). You say that you feel like the 
Plan should pay for this. The Plan denied your request. The Plan says D2740 and D2950 are not 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 crown 
(D2740) and a core build-up (D2950) provided by a participating provider on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral 
complete series of radiographic images (D0210) provided on May 19, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay the charges, and this 
was the only provider that was close by and could get you in for an appointment. 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 a comprehensive oral evaluation (D0150) and an intraoral complete series of radiographic images 
(D0210) provided on May 19, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided August 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that you need follow-up exams every three months. 
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 dates of service April 14, 2021, and 
October 18, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) provided August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen supplies (code A0422) billed during an ambulance 
transport for date of service February 17, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that this patient was denied incorrectly because 
the patient was residing in a skilled nursing facility at the time. The Plan denied your request. The Plan says it 
has overturned the denials for codes A0427, A0425, and A0999.  However, code A0422 is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. 
Therefore, we decided that the Plan does not have to pay for oxygen supplies (code A0422) billed during an ambulance 
transport for date of service February 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable supplies billed with code A0382 for date of 
service March 22, 2022. 
 You asked the Plan to pay for the ambulance supplies. You say that the medical records support payment. The 
Plan denied your request. The Plan says these supplies are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for disposable supplies billed with code A0382 for date of 
service March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #11 (D2332) 
provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth broke, and it needed to be repaired. 
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 a resin-based composite filling on tooth #11 (D2332) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that these services are medically necessary. 
The Plan denied your request. The Plan says core build up, per your EOC, is a benefit exclusion. 
 
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 
core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on May 
11, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test (D0431). You say that the amount for oral 
cancer screening is not significant. You say you feel the Plan should cover preventative dental preventative 
care. The Plan denied your request. The Plan says this service is not covered under your 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 pay for an 
adjunctive pre-diagnostic test (D0431) provided on May 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of skilled nursing 
facility admission. The Plan denied your request. The Plan says based on the clinical information provided the 
medical necessity has not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has left lower extremity deep vein thrombosis who received oral 
medications and had stable vital signs. The enrollee was at a supervision to minimal assist level with functional 
mobility including gait to 25 feet with a rolling walker. The enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found that the enrollee does not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings (D2391, D2392 x2) provided from June 1, 2022, 
through June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the 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 requested item or service was exhausted on date of service June 1, 2022. Therefore, 
we decided that the Plan does not have to pay for fillings (D2391, D2392 x2) provided from June 1, 2022, 
through June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental consultation (D0120), deep sedation (D9223 x4), 
the odontogenic cyst removal (D7451), the coronectomy (D7251), the extractions (D7210 x3) provided by an 
out-of-network provider from August 5, 2021, to September 30, 2021. 
 
You asked the Plan to pay for the dental consultation (D0120), deep sedation (D9223 x4), the odontogenic cyst 
removal (D7451), the coronectomy (D7251), the extractions (D7210 x3). You say that you submitted a 
Medicare medical claim for reimbursement of the services on September 30, 2021. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
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 dental consultation (D0120), 
deep sedation (D9223 x4), the odontogenic cyst removal (D7451), the coronectomy (D7251), the extractions 
(D7210 x3) provided by an out-of-network provider from August 5, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) and surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve the endosteal implant and surgical access. You say that you are not 
requesting multiple implants. The Plan denied your request. The Plan says these services are non-covered for 
the purpose of individual implants. 
 
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 implant benefit covers only the 
dental implant to hold a complete denture. The provided documentation does not show that you are requesting 
these implant services in order to hold a complete denture due to being completely toothless in the arch. 
Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: 
endosteal implant (D6010) and surgical access to an implant body (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), an abutment 
supported crown (D6059), and an endosteal implant (D6010) for tooth #11, provided by a participating 
provider. 
 
You asked the Plan to pre-approve dental implant services. You say that you need these implants because you 
cannot chew properly. The Plan denied your request. The Plan says the requested dental implants are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056), an abutment supported crown (D6059), and an endosteal implant (D6010) for 
tooth #11, provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740) and core build-ups (D2950) provided by a 
participating provider on March 28, 2022, to March 29, 2022. 
 
You asked the Plan to pay for crowns and core build-ups. You say that you needed these services done for a 
medical procedure. 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 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 crowns 
(D2740) and core build-ups (D2950) provided by a participating provider on March 28, 2022, to March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure 
(20985). 
 
You asked the Plan to pre-approve a computer-assisted surgical navigational procedure. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says medical-
necessity rules have not been met because the requested services are experimental/investigational. 
 
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 a computer-assisted surgical 
navigational procedure. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that there are no large-volume, long-term/high-quality 
clinical studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computer-assisted surgical navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computer-assisted surgical navigational 
procedure (20985).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says 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 Plan's 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 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83789-59 billed for date of service March 25, 2022. 
 
You asked the Plan to pay for code 83789-59. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says this code is not separately payable when billed for 
specimen validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789-59 have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for code 83789-59 billed for date of service March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure (D7999), intravenous 
moderate sedation (D9243 and D9239), and extractions (D7210), provided by an out-of-network provider on 
December 21, 2021. 
 
You asked the Plan to pay for an unspecified oral surgery procedure, intravenous moderate sedation, and 
extractions. You say that these services should be covered. The Plan denied your request. The Plan says the 
maximum dental yearly allowance 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 a yearly 
maximum dental allowance amount of $1,000 for covered benefits. 
  
We looked at the file and Medicare rules. Evidence was provided to show that the member has already met the 
yearly maximum dental allowance amount of $1,000. Based on this information, we decided that the Plan's 
rules for coverage of an unspecified oral surgery procedure, intravenous moderate sedation, and extractions 
have not been met. Therefore, we decided that the Plan does not have to pay for an unspecified oral surgery 
procedure (D7999), intravenous moderate sedation (D9243 and D9239), and extractions (D7210), provided by 
an out-of-network provider on December 21, 2021.