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

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a bone 
replacement graft for ridge preservation-per site (D7953 x 2). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 
upper partial denture has already been exhausted. Additionally, a bone replacement graft is not a covered 
benefit under your contractual policy. 
 
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 upper partial denture was exhausted on date of service September 1, 2020. 
Specifically, the Plans contract states that this dental item is covered once every five years. You previously 
received this item on September 1, 2020, which was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this item. Additionally, a bone replacement graft for ridge preservation is not covered. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a bone 
replacement graft for ridge preservation-per site (D7953 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recementing a crown on tooth #31 (D2920) provided on May 
20, 2021. 
 
You asked the Plan to pay for recementing a crown. You say that this service should be covered. The Plan 
denied your request. The Plan says recementing a crown (D2920) is not covered by your routine 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 
recementing a crown on tooth #31 (D2920) provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the irrigation of gingival pockets (D4921) 
 
You asked the Plan to pre-approve the irrigation of gingival pockets. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 pre-approve the 
irrigation of gingival pockets (D4921)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the modification of a prefabricated abutment and crown 
restoration services (D6056, D6065) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve the 
modification of a prefabricated abutment and crown restoration services (D6056, D6065)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware you no longer had dental 
coverage. You are on a fixed income, and you are not able to pay for the services provided. 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 dental services provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panoramic imaging (D0330) provided by a participating 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that this dentist needed to take this x-ray. 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 February 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve panoramic imaging (D0330) provided by a 
participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 85025) provided on April 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the tests were for screening purposes and are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (80053, 
85025) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arm braces to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve arm braces. You say that you need these for writing and daily life. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an OON provider or facility, and this was not an emergency. Therefore, the decision is 
upheld. 
 
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 
arm braces to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tires and inserts and transit 
system. 
 
You asked the Plan to pre-approve these services. You say that you use a loaner wheelchair for the majority of 
activites of daily living. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested propulsion tires and inserts and transit kit are for use outside of the home. Although these items 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic propulsion tires and inserts and transit system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the 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 pre-approve the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of root canal obstruction and biologic 
materials to aid in soft and osseous tissue regeneration (D3431, D3331) 
 
You asked the Plan to pre-approve the treatment of root canal obstruction and biologic materials to aid in soft 
and osseous tissue regeneration. You say that the services should be covered as you disagree with the denial. 
The Plan denied your request. The Plan says the services denied correctly as they do not fall within 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 pre-approve the 
treatment of root canal obstruction and biologic materials to aid in soft and osseous tissue regeneration (D3431, 
D3331)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of intraoral x-rays of the entire mouth (D0210) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you found this provider on the Plan's website. 
You also say you called the provider in 2021 to confirm insurance eligibility, at which point you were 
scheduled for an appointment. You say there were no openings in 2021 due to COVID-19. 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. You are responsible for understanding your 
benefits with the Plan and changes that are made from one contract year to another. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete series of intraoral x-
rays of the entire mouth (D0210) provided on May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84480 billed for date of service 
December 22, 2021. 
 
You asked the Plan to pay for procedure codes 84436 and 84480. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says the payment for codes 84436 and 
84480 is included in the payment for codes 84439 and 84481. 
 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 84436 
is a column II code to column I code 84439, and code 84480 is a column I code to column II code 84481. Both 
of these code pairs have a modifier indicator of 0. The column II codes are 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 codes 84436 and 84480 billed for date of service December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (D5213) and mandibular partial denture - cast metal framework with resin denture bases 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you think your partials were accidentally 
thrown away and you need to replace them. 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. Removable partial dentures 
(including routine post-delivery care) but is limited to 1 upper and/or 1lower partial denture every 5 calendar 
years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested maxillary partial denture - cast metal framework with resin denture bases 
(D5213) and mandibular partial denture - cast metal framework with resin denture bases (D5214) was 
exhausted on date of service February 5, 2022. Therefore, we decided that the Plan does not have to pre-
approve maxillary partial denture - cast metal framework with resin denture bases (D5213) and mandibular 
partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of intraoral x-rays of the entire mouth 
(D0210) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you the x-rays were necessary 
to fit the cap bridge correctly and accommodate for your bite. 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 the date of service because you received 
the services less than 60 months apart.  
 
 
 You received code D0210 on December 2, 2021, which means you would not be eligible for coverage of this 
service again until December 2, 2026. Therefore, we decided that the Plan does not have to pay for a complete 
series of intraoral x-rays of the entire mouth (D0210) provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service November 
28, 2021. 
 
You asked the Plan to pay for procedure code 12002. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 12002 is bundled into payment for code 26720. 
 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 12002 
is a column II code to column I code 26720. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12002 billed for date of service November 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services received were medically necessary. 
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 28, 2022, and 
June 13, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on June 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 25, 2022 billed with 
codes 81225, 81401, 81226, and 81400. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 25, 2022 billed with codes 81225, 81401, 81226, and 81400.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the frequency limit of 36 
weeks in your policy. You say you feel you should not be responsible for this charge when the hygienist should 
have known when the last panoramic was taken. 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 October 30, 2019. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) and the panoramic x-ray 
(D0330) provided on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not be charged because you went to 
a new dentist. The Plan denied your request. The Plan says your benefit for the comprehensive exam (D0150) 
and the panoramic x-ray (D0330) 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 December 8, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive exam (D0150) and the 
panoramic x-ray (D0330) provided on May 23, 2022.