Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and 
a joystick armor (K0108). 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has a medical history of 
polio. The enrollee is unable to ambulate, effectively complete weight shift throughout her day, and requires 
assistance for all transfers and most MRADLs. She requires the wheelchair base equipped with power recline 
in addition to power tilt and all recommended components to meet her mobility, medical & functional needs 
throughout her day in her home. The Plan denied your request. The Plan says the joystick is unbundled and 
cannot be approved. The joystick controller display is part of the Expandable Controller should not be 
requested separately. The Plan also says the electrical connection between the wheelchair controller and two or 
more motors, the expandable controller and harness cannot be covered. Although there are three requested 
power options (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
2 or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and a 
joystick armor (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says gingival irrigation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival 
irrigation (D4921 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tissue conditioning (D5851 x 3). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under the 
enrollee's 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, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve tissue 
conditioning (D5851 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of the waiting period. 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 14, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have this service mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service January 19, 2022. 
 
You asked the Plan this service mass spectrometry services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for code 
G0481; however, 83789 represents specimen validity testing which is not separately payable. 
 
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 mass spectrometry services 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 this service mass spectrometry and tandem mass spectrometry (83789) billed for 
date of service January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) 
 
You asked the Plan to pre-approve the dental services. You say that you misplaced your denture and need it 
replaced. 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 August 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an issue with your filling. 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 April 1, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral exam (D0140) provided June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
13, 2022. 
 
You asked the Plan to pay for the dental service. You say that the plan benefits allow for a comprehensive oral 
evaluation once every 6 months. You say that you have not exceeded this limit. You also say that this is the 
correct code. The Plan denied your request. The Plan says the frequency limit has been exceeded. 
 
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 the service is listed as covered, the 
frequency limit applies. The record shows that the Plan paid for a comprehensive oral evaluation that you 
received on March 24, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the laser treatment (D9999 x 4) provided on 
February 28, 2022. 
 
You asked the Plan to reimburse you for the laser treatment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the laser treatment is not listed as a covered dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the laser treatment is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the laser 
treatment (D9999 x 4) provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311), a harness for upgrade to expandable controller E2313), an 
expandable controller (E2377), a footplate bracket (K0108x2) and an ottobock hand pan (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the wheelchair and accessories are 
medically necessary. The Plan denied your request. The Plan says The electrical connection between the 
wheelchair controller and two or more motors, expandable controller and harness cannot be covered. Although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. There is a request for a foot plate/bracket assembly. This part 
is miscoded; K0108 must not be used for items that have a specific HCPCS code. A hand pad does not serve a 
medical need and cannot be covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
2 or more power seating system motors (E2311), a harness for upgrade to expandable controller E2313), an 
expandable controller (E2377), a footplate bracket (K0108x2) and an ottobock hand pan (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) on tooth #12 provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believed that you had $2,000 to use towards 
dental costs. You say you feel one crown 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 crown was exhausted on date of service April 12, 2022, on tooth #13. Therefore, we 
decided that the Plan does not have to pay for the crown (D2740) on tooth #12 provided on April 12, 2022.  
 
Your complaint that the benefit description is misleading 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7311) 
provided on April 19, 2022. 
 
You asked the Plan to pay for the alveoloplasty. You say that you should be refunded. The Plan denied your 
request. The Plan says this service is not covered by your health plan or Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
alveoloplasty in conjunction with extractions (D7311) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional procedures to customize a crown on tooth #5 
(D2971). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says additional procedures to customize a crown (D2971) are 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 pre-approve 
additional procedures to customize a crown on tooth #5 (D2971).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 17, 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 a covered benefit, but the enrollee has 
exceeded limits set in the subscriber agreement. 
 
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. Therefore, we decided that the Plan does 
not have to pay for the dental services on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), and to pay more for the 
complete maxillary denture (D5110), and mandibular partial denture (D5214) provided on May 24, 2022, by an 
out-of-network (OON) provider. 
 
  You asked the Plan to pay for the preventive procedure, or pay more for the complete maxillary denture, and 
mandibular partial denture. The Plan denied your request. The Plan says the preventive procedure is not a 
covered expense under your dental plan. The Plan also says that these services were performed by a non-
participating provider, and you are responsible for any difference between the Maximum Allowable Fee and 
the amount the provider bills you for the services. 
 
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 preventive procedure (D1999) is 
not among those covered under this benefit. The contract clearly states that you are responsible for a 50% 
coinsurance for each denture, plus the difference between the billed amounts and allowed amounts because 
these services were received OON. Therefore, we decided that the Plan does not have to pay for the preventive 
procedure (D1999), and to pay more for the complete maxillary denture (D5110), and mandibular partial 
denture (D5214) provided on May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6065) and prefabricated 
abutments (D6056) provided by a participating provider. 
 
You asked the Plan to pre-approve implant supported crowns and prefabricated abutments. You say that you 
already started these services, and you need to finish the procedure. The Plan denied your request. The Plan 
says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant supported crowns (D6065) and prefabricated abutments (D6056) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
adjunctive pre-diagnostic test (D0431) provided on July 7, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and adjunctive pre-diagnostic test. You 
say that you believe x-rays should be included as part of a dental exam, and you should not be charged for 
them. You also say that the price of the x-rays seems too expensive. The Plan denied your request. The Plan 
says these services are not covered expenses under your dental plan. The Plan also says when you contacted the 
Plan prior to the date of service, you requested assistance with locating a par provider, but did not request 
benefit details for any services during the call. 
 
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 
complete series of intraoral x-rays (D0210) and adjunctive pre-diagnostic test (D0431) provided on July 7, 
2022.
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 it is necessary to have the procedure. 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 pay for the comprehensive oral evaluation (D0150) provided on June 
13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were given a two-page 
recommendation list of treatment that you needed, but you did not agree with it. You also say that you 
consulted with two other dentists, who advised the treatments were unnecessary. 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 May 9, 2022.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that insurance should pay a portion of the expense 
due to $2,000 in dental benefits being available. The Plan denied your request. The Plan says these services are 
not covered by the Plan's 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 the crown 
(D2740) and core buildup (D2950) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) 
 
You asked the Plan to pre-approve the bone replacement. 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 a 
bone replacement graft (D7953)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on April 22, 2022. 
 
You asked the Plan to pay for the consultation. You say that you would like to be reimbursed the correct 
amount for this service. The Plan denied your request. The Plan says this service 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 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 
consultation (D9310) provided on April 22, 2022.