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

 
We decided that the Plan does not have to pre-approve implant placement for teeth #'s 10, 11, 12, 13, 14, 15, 
18, 19, 2, 3, 30, 31, 4, 5, 6, and 7 to be provided by a network provider. 
 
You asked the Plan to pre-approve implant placement for teeth #'s 10, 11, 12, 13, 14, 15, 18, 19, 2, 3, 30, 31, 4, 
5, 6, and 7. You say that you are appealing the denial of the services. You say tried dental prosthesis for one 
year but was intolerant to adhesive paste which causes irritable gums. You say the dental implants should be 
provided. The Plan denied your request. The Plan says the services are 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 implants are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement 
for teeth #'s 10, 11, 12, 13, 14, 15, 18, 19, 2, 3, 30, 31, 4, 5, 6, and 7 to be provided by a network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for overnight medical services (99053) provided on September 
18, 2021. 
 
You asked the Plan to pay for overnight medical services. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of overnight medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
overnight medical services (99053) provided on September 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radical resection services coded 42844, the ligation 
services coded 37615, and the laryngoscopy direct services coded 31526 provided on August 23, 2021. 
 
You asked the Plan to pay for the Radical resection services, the ligation services, and the laryngoscopy direct 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 42844, 37615, 31526 is not supported in the medical record. Specifically, the operative 
report did not include documentation of a radical resection of the tonsil, tonsillar pillars, and/or retromolar 
trigone; closure with local flap (tongue, buccal); therefore, code 42844 cannot be verified. While services 
identified with code 37615 were documented in the operative report narrative, the procedure is inclusive to the 
main procedure. This means this code is not separately payable. Services identified with code 31526 were 
documented in the operative report narrative, this procedure is inclusive to code 41120 (a glossectomy; for less 
than one-half tongue). This means this code is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of the Radical resection services, the 
ligation services, and the laryngoscopy direct services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Radical resection services coded 42844, the ligation services coded 37615, and the 
laryngoscopy direct services coded 31526 provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) and the local anesthesia 
(D9215). 
 
You asked the Plan to pre-approve dental codes D4921 and D9215. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says dental codes D4921 and D9215 are not 
covered under the Plan's supplemental dental 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, dental codes D4921 and D9215 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
gingival irrigation (D4921) and the local anesthesia (D9215).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental reconstruction services (D9999) provided to the
enrollee on June 2, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this 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
the enrollee's teeth or the structures directly supporting the enrollee's 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
reconstruction services (D9999) provided to the enrollee on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine dental visits with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve OON routine dental visits. You say that you and your family have been 
using this dentist for 15-20 years. The Plan denied your request. The Plan says these services are not covered 
OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers OON routine 
dental visits when the services are rendered by a participating provider. 
 
 We looked at the file and Medicare rules. 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 cover these items/services. Based on this information, we 
decided that the Plan's rules for coverage of OON routine dental visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve routine dental visits with an out-of-network (OON) 
provider.  
 
Your complaint about your long-time provider not being covered under the Plans dental network is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first hour of critical care (99291) provided on April 28, 2021. 
 
You asked the Plan to pay for the first hour of critical care. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the available medical 
documentation does not record the span of time devoted to evaluation and management of the enrollee's critical 
condition. Based on this information, we decided that Medicare rules for coverage of the first hour of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for the first hour of critical 
care (99291) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a comprehensive oral 
evaluation (D0150), panoramic radiographic imaging (D0330), and prophylaxis (D1110), provided by an out-
of-network provider on February 15, 2022, to February 22, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation, a comprehensive oral evaluation, panoramic 
radiographic imaging, and prophylaxis. You say that you were told that you were covered up to $2,000. The 
Plan denied your request. The Plan says the services provided have been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation, a comprehensive oral evaluation, panoramic radiographic imaging, and 
prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation (D0120), a comprehensive oral evaluation (D0150), panoramic radiographic imaging (D0330), and 
prophylaxis (D1110), provided by an out-of-network provider on February 15, 2022, to February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110). 
 
You asked the Plan to pre-approve an abutment supported removable upper denture. You say that the enrollee 
needs this service. The Plan denied your request. The Plan says the enrollee will exceed the frequency limit for 
this service. 
 
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 an abutment 
supported removable upper denture once every five calendar years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture 
(D5110) was previously covered October 7, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of an abutment supported removable upper denture will be exceeded with the requested service. Therefore, we decided that the Plan does not have to pre-approve an implant /abutment 
supported removable denture for edentulous arch  maxillary (D6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-bonding of a crown (D2920) provided by a 
participating provider on February 28, 2022. 
 
You asked the Plan to pay for the re-bonding of a crown. You say that you did not know that this was not 
covered. The Plan denied your request. The Plan says this claim has been correctly processed and denied. 
 
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 re-
bonding of a crown (D2920) provided by a participating provider on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided by a participating 
provider on February 2, 2022. 
 
You asked the Plan to pay for an endosteal implant. You say that you would like the Plan to pay 50% of this. 
The Plan denied your request. The Plan says the rendered dental services are not covered. 
 
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 
endosteal implant (D6010) provided by a participating provider on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device evaluation (93295) provided on December 13, 2021.
You asked the Plan to pay for interrogation device evaluation. You say that you have provided records to support the service billed. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that remote interrogation services 93295 and 93296 are 90-day services and may only be reported once during that period regardless of the number of interrogations performed.
We looked at the file and Medicare rules. In this case, the Plan has documented that procedure code 93295 was previously billed within 90 days of the date of service at issue. Based on this information, we decided that Medicare rules for coverage of interrogation device evaluation have not been met. Therefore, we decided that the Plan does not have to pay for interrogation device evaluation (93295) provided on December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report provided on September 8, 2021, billed with code 93010.
You asked the Plan to pay for the EKG interpretation and report. You say that this was a separately identifiable interpretation that was used in the management of the patient. The provider is entitled to payment for this service. The Plan denied your request. The Plan says no records were submitted to support separate payment is due for this service.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the electrocardiogram (EKG) interpretation and report provided on September 8, 2021, billed with code 93010. have been met. Specifically, no documentation was submitted to support that the interpretation and report being billed on this claim was unrelated or separate to the EKG report provided by another provider on the same date. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report provided on September 8, 2021, billed with code 93010.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on February 
25, 2021, to December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
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 until July 26, 2023. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on February 25, 2021, to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x 5), and implant 
supported crowns (D6065 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that the implants are necessary. You say that 
you have chewing and digestive problems. You also say that this is an urgent situation. The Plan denied your 
request. The Plan says dental implants and all associated services are excluded from coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested prefabricated abutments 
and implant supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve prefabricated abutments (D6056 x 5), and implant supported crowns (D6065 
x 5).
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) and intraoral - complete series of radiographic images (D0210) provided February 26, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you 
had a miscommunication with the dental office. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for these 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. The Plan covers the 
comprehensive oral exam once every 3 calendar years and complete series of x-rays or panoramic x-ray once 
every 5 calendar years.  
 
We looked at file and Medicare rules. The Plan provided documentation showing that a comprehensive exam 
and panoramic x-ray were previously covered on February 13, 2020. Based on this information, we decided 
that the Plan's frequency limits for coverage of the comprehensive oral exam and complete series of x-rays 
have been exceeded.  Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided February 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) to be provided by 
a network provider. 
 
You asked the Plan to pre-approve the complete maxillary denture (D5110). You say that your dentures broke 
in half while eating and need to be replaced. You say the loss of use for your dentures prevents you from 
chewing any solid food. 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 complete maxillary denture 
(D5110) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve a complete maxillary denture (D5110) to be provided by a network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology interpretation rendered on 
September 29, 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 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 G0452 
is a column II code to column I code 81455. 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 the molecular pathology interpretation rendered on September 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code.
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on December 
15, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
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 until August 31, 2022. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110), complete lower denture 
(D5120), and embedding (D5899 x 2) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not get your dentures until February 11, 
2022. You say that they were only covered at 30% because you were initially seen in 2021. You also say that 
these should be covered at 100%. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and dentures are listed as covered, there 
is a 70% coinsurance when you receive them in network. This is a contractual obligation you agreed to when you enrolled in the Plans dental coverage. Additionally, embedding is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110), 
complete lower denture (D5120), and embedding (D5899 x 2) provided on November 17, 2021.