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

 
We decided that the Plan does not have to pay for dental work-crown on December 13, 2021. 
 
You asked the Plan to pay for dental work-crown. You say that you would like to appeal the denial of payment. 
The Plan denied your request. The Plan says these services are excluded, per the member's EOC. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental work-crown on December 
13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep cleaning on all four quadrants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there needs to be at least four teeth in the quadrant. 
 
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 services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the 
documentation provided did not include periodontal charting indicating periodontal pathology. The radiographs 
did not show at least four teeth in each of the four quadrants nor subgingival calculus buildup on the teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve deep cleaning on all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on 
February 8, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you wanted to see the oral surgeon without 
having to go to the dentist, but you required a referral. It was necessary for you to have the visit on February 8, 
2022, in order to schedule tooth extractions. The Plan denied your request. The Plan says you had already 
exhausted your benefit for this service, so you are not eligible for coverage. 
 
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's rules explicitly 
state that limited oral exams (code D0140) are only covered once per plan year.  This restriction applies 
regardless of the reason for the exam.  You had already received covered limited oral exam on January 31, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral exam (code D0140) you received on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81260 and 81292) provided on 
October 5, 2021. 
 You asked the Plan to pay for codes 81260 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81260 and 81292) provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 27, 2021, billed with 
codes 81206, 81275, 81276, and 81301. 
 
You asked the Plan to pay for the testing as billed. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this panel should be billed with a single code. As such, only 7 of the 11 
codes billed are approved for payment. 
 
The Plan must follow Medicare rules. Medicare 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 testing is an NGS panel of multiple genes that was not billed 
with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of 
the testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on August 27, 2021, billed with codes 81206, 81275, 81276, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction of teeth #23 through #29 (D7140  7), and an 
unspecified removable prosthodontic procedure (D5899) provided on December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that you cannot afford to pay the remaining amount. 
You also say the provider's staff gave you misinformation on coverage. The Plan denied your request.  
The Plan says the denial of payment for these services is correct because the services are not covered by the 
Plan's supplemental dental benefits, or the services are covered but the coverage benefit has been exhausted at 
the time of service. 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 two 
extractions each calendar year, but the Plan does not cover unspecified removable prosthodontic procedures. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received one extraction on 
November 2, 2021; thus, the extraction of tooth #22 is covered at a negotiated rate. However, the benefits for 
additional extractions of teeth #23 through #29 were exhausted on December 2, 2021. Additionally, the 
unspecified removable prosthodontic procedure is not covered by the Plan. Therefore, we decided that the Plan 
does not have to pay for extraction of teeth #23 through #29 (D7140  7) and an unspecified removable 
prosthodontic procedure (D5899) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on February 15, 2022. 
 
You asked the Plan to pay for the consultation. You say that you were told the services would be covered. The 
Plan denied your request. The Plan says the consultation is not covered under your supplemental dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and periapical imaging 
(D0220) provided by an out of network provider on September 13, 2021. 
 
You asked the Plan to pay for the oral evaluation and imaging. You say that you should have been seen by one 
of the dentists in the office who is in-network with the Plan. The Plan denied your request. The Plan says dental 
services are not covered when received from an out of network provider. 
 
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 periapical imaging (D0220) provided by an out of network provider on September 
13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided January 19, 2022. 
 
You asked the Plan to pay for the additional periapical x-ray. You say that you would like the Plan to pay the 
full bill. The Plan denied your request. The Plan says you have exceeded 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 Plan's coverage rules apply in this case. The Plan covers the additional 
periapical x-ray once per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that one periapical x-ray 
was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit 
for coverage of the additional periapical x-ray has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the intraoral - periapical each additional radiographic image (D0230) provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical - 1st radiographic image (D0220) and other drugs 
(D9630) provided on January 24, 2022, and a limited oral evaluation (D1040) and periapical - 1st radiographic 
image (D0220) provided on February 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the imaging, drugs, and evaluation. You say that these services should be 
covered. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 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 only 
covered when provided by an in-network provider. Therefore, we decided that the Plan does not have to pay for 
periapical - 1st radiographic image (D0220) and other drugs (D9630) provided on January 24, 2022, and a 
limited oral evaluation (D1040) and periapical - 1st radiographic image (D0220) provided on February 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and endodontic therapy (D3320) 
provided on March 17, 2022. 
 
You asked the Plan to pay for the core buildup and endodontic therapy. You say that you were told the services 
would be covered 100%. The Plan denied your request. The Plan says the services are not covered by your 
supplemental 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 core 
buildup (D2950) and endodontic therapy (D3320) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper and lower dentures (dental codes D5110 and 
D5120) provided on February 22, 2022. 
 
You asked the Plan to pay for the upper and lower dentures. You say that the prior dentures did not fit 
anymore, and you would like the Plan to cover them. The Plan denied your request. The Plan says this service 
is covered by the Plan's dental benefits; however, your benefit for covered for 1 upper and 1 lower complete 
denture for every 5 calendar years has 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. The Plan covers 1 upper and 1 
lower complete denture for every 5 calendar years. 
 
  We looked at this the file, the Plans rules, and Medicare rules. The Plan approved coverage for 1 upper and 1 lower 
complete denture on October 31, 2019; therefore, the benefit for the upper and lower dentures has been exhausted. 
Based on this information, we decided that the Plan's rules for coverage of the upper and lower dentures have not 
been met. Therefore, we decided that the Plan does not have to pay for the upper and lower dentures (dental 
codes D5110 and D5120) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81230, 81240, 81241, 81249, 81291, 
81408, and 81335) provided on August 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81230, 81240, 81241, 81249, 81291, 81408, and 81335) provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and panoramic x-rays 
(D0330) provided on February 15, 2022. 
 
You asked the Plan to pay for the oral evaluation and x-rays. You say that you did not know the provider was 
out of network with the Plan. The Plan denied your request. The Plan says dental services are not covered by 
your supplemental benefits when received from an out of network provider. 
 
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 panoramic x-rays (D0330) provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292) provided on 
September 13, 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 based on the medical records. The Plan denied your request. The Plan says this 
claim has not been billed in accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. 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 (81206, 81292) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (code D0330), complete dentures (code 
D5110), and an extraction (code D7140) provided on February 14, 2022. 
 
You asked the Plan to pay for an x-ray, dentures, and an extraction.. You say that this was an emergency, and 
you needed these services. The Plan denied your request. The Plan says that services provided by an out-of-
network provider are not covered. The Plan also says that complete dentures (D5110) and an extraction (code 
D7140) are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you went to an out-of-network provider. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for a panoramic x-ray (code D0330), complete dentures (code 
D5110), and an extraction (code D7140) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, and 81301) 
provided on October 11, 2021. 
 
You asked the Plan to pay for codes 81206, 81275, 81276, and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81275, 81276, and 81301) provided on October 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (code A0382) provided during ambulance transport 
on February 26, 2022. 
 
You asked the Plan to pay for the supplies. You say that these services were medically necessary The Plan 
denied your request. The Plan says supplies are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies are not separately payable from the 
ambulance services themselves and are included in the base rate for the transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met.  
 
Therefore, we decided that the Plan does not have to pay for supplies (code A0382) provided during ambulance 
transport on February 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided December 10, 2021. 
 
You asked the Plan to pay for the root canal. You say that you feel this should be covered under your medical 
benefits because the service was related to a fall. The Plan denied your request. The Plan says this service is not 
covered under your medical or 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. This service is also not eligible for coverage under your medical 
benefits.  Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) provided December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a dental cleaning 
(D1110), and bitewing x-rays (D0274) provided by an out of network provider on February 1, 2022. 
 
You asked the Plan to pay for the oral evaluation, cleaning, and x-rays. You say that your provider said they 
took your insurance. The Plan denied your request. The Plan says dental services are not covered by your 
supplemental dental benefits when received from an out of network provider. 
 
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 periodic 
oral evaluation (D0120), a dental cleaning (D1110), and bitewing x-rays (D0274) provided by an out of 
network provider on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (code D3310) provided on 
April 26, 2021, and the porcelain crown (code D2752) and core build up (code D2950) provided on May 10, 2021. 
 
You asked the Plan to pay for the endodontic and crown services. You say that your dental insurance was 
dropped by the Plan. The Plan denied your request. The Plan says endodontic and crown services are not 
covered under your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
endodontic therapy, anterior tooth (code D3310) provided on April 26, 2021, and the porcelain crown (code 
D2752) and core build up (code D2950) provided on May 10, 2021.