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

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), and consultation (D9310) 
provided on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain. You say that you needed a 
tooth extraction. You also say that you were not advised this would not be covered. The Plan denied your 
request. The Plan says the services you received are not listed as 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 surgical extraction and consultation 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the surgical extraction (D7210), and consultation (D9310) provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided March 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that this was a basic cleaning and should be covered. 
The Plan denied your request. The Plan says the services were provided out-of-network and are only a covered 
benefit when obtained in-network with the 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. The Plan covers the 
prophylaxis when obtained in-network and the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The prophylaxis was provided out-of-network, so it is not covered by 
your supplemental dental benefits. Therefore, we decided that the Plan does not have to pay for the prophylaxis 
(D1110) provided March 29, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided on August 17, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 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 A4557 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4557 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
lead wires provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and two 
surgical extractions (D7210 x2) provided on March 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and surgical extractions. You say that 
the two in-network providers you contacted could not get you in before your aortic valve replacement 
scheduled for April 19, 2022. The Plan denied your request. The Plan says services performed by an OON 
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you 
contacted the Plan prior to the date of service to verify benefits and provider eligibility, and you were sent the 
benefits and provider's list by mail. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive periodontal evaluation (D0180) and two surgical extractions (D7210 x2) provided on 
March 31, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast implants and reconstruction services. 
 
You asked the Plan to pre-approve the requested services. You say that you have endured continual pain. The 
Plan denied your request. The Plan says the request is not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that breast implants and reconstruction services were requested. We looked at the file, and 
Medicare rules. Cosmetic surgery directed at improving appearance is not a covered service. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve breast implants and reconstruction services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for prophylaxis (D1110), comprehensive oral 
evaluation (D0150), and intraoral x-rays (D0210) provided on April 1, 2022. 
 
You asked the Plan to pay the full amount for the dental services. You say that you were told the provider was 
in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for prophylaxis (D1110), comprehensive oral evaluation (D0150), and intraoral x-rays (D0210) 
when received by an out-of-network provider. The contract also says that you are responsible for any difference 
between the maximum allowable fee and the amount the provider bills you for the services. 
 
The record shows you received the requested dental services from an out-of-network provider. You have been 
asked to pay a total of $139.50, which is the difference between the amount billed to you by the provider and 
the amount the Plan paid ($224 amount provider billed you - $84.50 Plan paid = $139.50). This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay the full amount for prophylaxis (D1110), comprehensive oral evaluation (D0150), and 
intraoral x-rays (D0210) provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build up (D2950) and a crown (D2740) for teeth #8 
and #9 provided by a participating provider on December 9, 2021. 
 
You asked the Plan to pay for a core build up and a crown. You say that you are waiting for the Plan to pay for 
this. The Plan denied your request. The Plan says D2950 is not a covered benefit. D2740 has 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. 
 
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 core 
build up (D2950) because it is not covered. The crowns (D2740) for teeth #8 and #9 have been processed, 
leaving a 70% coinsurance for the enrollee. The total allowed amount for D2740 is $1,876. The total amount 
you are being asked to pay for the crowns is $1,313.20 (D1,876 x 70% = $1,313.20).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of gingival inflammation (D4346) 
provided by a participating provider on March 9, 2022. 
 
You asked the Plan to pay for scaling in presence of gingival inflammation. You say that you were unaware 
this was not covered. The Plan denied your request. The Plan says the rendered dental service is 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 scaling in 
presence of gingival inflammation (D4346) provided by a participating provider on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the two occlusal guards (D9944 x2) provided on February 1, 2022. 
 
You asked the Plan to pay for the occlusal guards. You say that these guards are medically necessary, and you 
would like them approved for coverage. The Plan denied your request. The Plan says that this service is not 
covered under your benefit 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. 
 
We looked at the file and Medicare rules. The contract states that you have a $1,500 dental allowance for 
comprehensive dental services. The 2022 Evidence of Coverage does not clearly state exactly which dental 
services are and/or are not covered, and also says that other services are covered. The documentation does not 
state which dental Plan you are under. The record also does not show that you have exhausted your $1,500 
dental allowance. You reasonably believed the occlusal guards would be covered because you have a $1,500 
benefit, and the Evidence of Coverage is not clear on which dental services are covered. Based on this 
information, we decided that the Plan's rules for coverage of the occlusal guards have been met. Any amount 
over the $1,500 allowance will be your responsibility. Therefore, we decided that the Plan has to pay for the 
two occlusal guards (D9944 x2) provided on February 1, 2022.  
 
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 the comprehensive oral evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable 
benefit for the services provided in this case. 
 
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 that you previously received these services on June 9, 2021, which were paid for by the Plan. The Plan 
contract states that one procedure is covered every three plan years for each service at issue. Therefore, you 
have exhausted the allowable benefit for these services.  Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic 
images (D0210) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel the first provider did not do their job 
correctly, which led you to suffer various dental problems. You also say that you should be refunded back the 
amount for that service, and this visit 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 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 July 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on December 21, 2021. 
 
You asked the Plan to pay for the testing services. You say that drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the services cannot be separately reimbursed. 
 
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. The testing described by the billed code is considered specimen 
validity testing which is not separately payable. Therefore, we decided that the Plan does not have to pay for 
the validity testing provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 22, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the documentation provided does not 
support payment for the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. In this case, the documentation from the enrollees physician does 
not clearly document the intent that the test be performed. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing services provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) and two drugs or 
medicaments dispensed in the office for home use (D9630 x2) provided on January 10, 2022. 
 You asked the Plan to pay for the gingival irrigations and drugs or medicaments. You say that you would like 
to appeal these services. The Plan denied your request. The Plan says these services are not covered benefits 
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 four 
gingival irrigations (D4921 x4) and two drugs or medicaments dispensed in the office for home use (D9630 x2) 
provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) 
provided March 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the provider is charging too much. 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 18, 2021. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior 
(D2331) provided March 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided on December 16, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied payment for a missing condition code for end stage 
renal disease (ESRD). However, the claim does not show that the enrollee has a diagnosis of ESRD. As this is 
the only reason the Plan denied payment, we find that the Plan has provided insufficient evidence to support 
their reasoning for the denial. Therefore, we decided that the Plan has to pay for the outpatient hospital services 
provided on December 16, 2021.  
 
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 comprehensive oral evaluation (D0150) provided by a 
participating provider on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were 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 June 5, 2019. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture (D9120), guided tissue regeneration 
(D4267), and bone replacement graft (D7953) provided February 28, 2022, and an interim maxillary partial 
denture (D5820) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services 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 pay for a fixed 
partial denture (D9120), guided tissue regeneration (D4267), and bone replacement graft (D7953) provided 
February 28, 2022, and an interim maxillary partial denture (D5820) provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says there is 
no evidence that you need a CPAP. 
 The Plan follows Medicare rules. Medicare rules say that continuous positive airway pressure devices are only 
covered under certain medical indications. 
 
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 requested device. Our physician 
reviewer found that you have severe chronic obstructive pulmonary disease (COPD) and a history of severe 
OSA on a sleep study years ago. The most recent home sleep study, done while on oxygen, did not show OSA; 
the AHI was normal at 2.4. However, the oxygen flow may have interfered with testing. Given the severe lung 
disease, you need an attended sleep study and PAP titration. Because the most recent sleep study did not show 
OSA, the CPAP is not medically necessary. 
 
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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0220 and D0230), provided by a participating provider on March 9, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you fell and lost 
your front tooth. You say that you needed these services. The Plan denied your request. The Plan says the 
dental services provided 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 a limited 
oral evaluation (D0140) and intraoral imaging (D0220 and D0230), provided by a participating provider on 
March 9, 2022.