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

 
We decided that the Plan does not have to pay for semi-precision abutment - placement (D6191), semi-
precision attachment - placement (D6192), and connecting bar - implant-supported or abutment supported 
(D6055) provided February 15, 2022. 
 
You asked the Plan to pay for the semi-precision abutments and attachments and connecting bar. You say that 
these dental services were necessary for the quality of your life. 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 
semi-precision abutment - placement (D6191), semi-precision attachment - placement (D6192), and connecting bar 
- implant-supported or abutment supported (D6055) provided February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
26, 2022. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the service at issue 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 
panoramic radiographic image (D0330) provided on May 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are available with equally qualified in-network board-certified Urological-Oncologists, Urologists, and 
Medical Oncologists that treat prostate cancer and IgM kappa monoclonal gammopathy. The enrollee can see 
multiple providers for second opinion consultations, including those who obtained their fellowship at the 
center for oncological conditions, national cancer institutes (NCI) and practice in Tertiary medical 
center for oncologist conditions. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion to be provided 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 removal of impacted tooth (D7240) provided on April 27, 2021. 
 
You asked the Plan to pay for the removal of impacted tooth. The Plan denied your request. The Plan says the 
service provided 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 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 
removal of impacted tooth (D7240) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was necessary to take additional x-rays. 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 March 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image 
(D0220) provided June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on February 22, 2022. 
 
You asked the Plan to pay for a consultation. You say that you should not be responsible for this charge. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a shoulder 
arthroplasty procedure. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that the shoulder replacement surgery may be safely performed with a 48-
hour observational stay. An inpatient stay is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a shoulder arthroplasty procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) pelvis (72197). 
 
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the MRI of Pelvis is not medically 
necessary to follow the lesion in the pancreas. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of pancreatic cancer (neuroendocrine tumor in body of pancreas, 
shown on CT/PET). The enrollee did not have objective signs of abnormality in the pelvic area and as the 
pancreas was the primary area intended to be examined by imaging, pelvic imaging is not needed. Therefore, 
this request for MRI pelvis will be considered not medically necessary or reasonable based on the provided 
documentation. The Plan's denial is justified as the MRI of the abdomen should be sufficient to evaluate the 
area where the cancer is involved. 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) pelvis (72197).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and full mouth 
complete x-ray (D0210) provided by a participating provider on February 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should 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 the requested item or service was exhausted on date of service July 11, 2019. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and full mouth 
complete x-ray (D0210) provided by a participating provider on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis - adult 
(D1110) provided on January 10, 2022, and the Plan does not have to pay for pin retention - per tooth (D2951), 
resin-based composite - four or more surfaces (D2394), resin-based composite - one surface (D2391 X 3), and 
inhalation of nitrous oxide/analgesia (D9230) provided on February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were assured the provider was in-network. 
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 periodic oral evaluation (D0120) and prophylaxis - adult (D1110) provided on January 10, 2022, 
and the Plan does not have to pay for pin retention - per tooth (D2951), resin-based composite - four or more 
surfaces (D2394), resin-based composite - one surface (D2391 X 3), and inhalation of nitrous oxide/analgesia 
(D9230) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal orthotic device (D7880) received on January 11, 2022. 
 
You asked the Plan to pay for an occlusal orthotic device. You say that you want the Plan to pay for this 
service. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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 an occlusal orthotic device 
(D7880) received on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93452 billed for date of service June 21, 2021. 
 
You asked the Plan to pay for procedure code 93452. You say that this claim was underpaid. The Plan denied 
your request. The Plan says payment for this code is bundled into payment for code 93454.  
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 93452 
is a column II code to column I code 93454 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93452 billed for date of service June 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 and an additional unit of code 97012 
billed for date of service November 15, 2021. 
 
You asked the Plan to pay for procedure code 97010 and an additional unit of code 97012. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
procedure code 97010 is considered bundled and not separately payable. The Plan says the records do not 
support more than one unit of code 97012. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable.  
 
The definition of code 97012 is Application of a modality to 1 or more areas; traction, mechanical. We find that 
the second unit of code 97012 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of procedure code 97010 and an additional unit of code 97012 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 97010 and an additional unit 
of code 97012 billed for date of service November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #15 (D2950) provided on April 7, 2022. 
 
You asked the Plan to pay for core build up. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says core build up (D2950) is not covered by 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 Plan's coverage rules apply in this case. 
 
The medical record shows you received core build up on April 7, 2022. 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 core build up on tooth #15 (D2950) provided on 
April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom abutment (D6057) and an abutment supported 
crown (D6058) provided by an out-of-network provider on March 2, 2022, to April 1, 2022. 
 
You asked the Plan to pay for a custom abutment and an abutment supported crown. You say that you believe 
the Plan should pay for this. The Plan denied your request. The Plan says the rendered dental work 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 custom 
abutment (D6057) and an abutment supported crown (D6058) provided by an out-of-network provider on 
March 2, 2022, to April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bitewing x-rays (D0274), 
and a panoramic x-ray (D0330) provided on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you requested a list of preferred dental 
providers, and the list clearly shows the provider's office. 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 limited oral evaluation (D0140), bitewing x-rays (D0274), and a panoramic x-ray (D0330) 
provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic 
images (D0274), and teeth cleaning (D1110) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that they accepted 
your insurance, and the visit would be covered. The Plan denied your request. The Plan says routine dental 
services were provided by an out-of-network provider and are not covered because they were not authorized by  
the Plan and not emergent. General dentistry services are only covered when rendered from the assigned 
facility. 
 
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 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 periodic oral evaluation (D0120), bitewing radiographic images (D0274), and teeth cleaning 
(D1110) provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the K3 foot. 
 
You asked the Plan to pre-approve the K3 foot. You say that the item is necessary. The Plan denied your 
request. The Plan says that the K3 foot exceeds the enrollee's needs 
 
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 K3 foot. Our physician reviewer 
found the physician is responsible for ordering the device and there are no contraindications for the enrollee to 
receive the device. 
 
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 K3 foot have been met. Therefore, we decided that the Plan has to pre-
approve the K3 foot.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluoride varnish (D1206) and prophylaxis (D1110) 
provided by an out-of-network provider on April 25, 2022. 
 
You asked the Plan to pay for a fluoride varnish and prophylaxis. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services are not covered by the 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 pay for a fluoride 
varnish (D1206) and prophylaxis (D1110) provided by an out-of-network provider on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed the emergency dental work done. 
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 August 25, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 7, 2022.