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

 
We decided that the Plan does not have to pay for the consultation-diagnostic service rendered by a dentist or 
physician other than the requesting dentist or physician (D9310) on March 8, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation-diagnostic service rendered by a dentist or physician other than the requesting dentist or physician 
(D9310) on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for several teeth. 
 
You asked the Plan to pre-approve removal of residual tooth roots. You say that these services are necessary. 
The Plan denied your request. The Plan says this procedure is not covered by your dental benefit. 
 
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 pre-approve 
removal of residual tooth roots (D7250) for several teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture with cast metal framework 
(D5213). 
 
You asked the Plan to pre-approve a partial upper denture. You say that your denture fell and broke, so you 
need a replacement. The Plan denied your request. The Plan says you previously received a partial upper 
denture on May 12, 2021. Your dental benefit covers a maximum of one removable denture per arch every five 
years. 
 
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 can cover up to one 
removable denture per arch every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
upper denture is requested in a frequency that is not covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture with cast metal framework (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture realignment. 
 
You asked the Plan to pre-approve a denture realignment. You say that you cannot afford to pay out of pocket 
for the denture adjustment. The Plan denied your request. The Plan says this service is not a covered benefit 
under Medicare. 
 
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 pre-approve a 
denture realignment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225) and a partial lower 
denture (D5226). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5225) and a partial lower denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant removal (D6100), the collection and 
application of autologous blood concentrate product (D7921), a bone replacement graft for ridge preservation-
per site (D7953), and therapeutic parenteral drugs, two or more administrations of different medications 
(D9612). 
 
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 these services are not a covered benefit under your 
contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit.  
 Therefore, we decided that the Plan does not have to pre-approve an implant removal (D6100), the collection 
and application of autologous blood concentrate product (D7921), a bone replacement graft for ridge 
preservation-per site (D7953), and therapeutic parenteral drugs, two or more administrations of different 
medications (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of plaque (D1110) provided on March 14, 2022. 
 
You asked the Plan to pay for the removal of plaque. 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 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 
removal of plaque (D1110) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibular (D7473) and 
therapeutic parenteral drugs (D9612), provided by a participating provider. 
 
You asked the Plan to pre-approve the removal of torus mandibular and therapeutic parenteral drugs. You say 
that these services are medically necessary. 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 the 
removal of torus mandibular (D7473) and therapeutic parenteral drugs (D9612), provided by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services need to be received in-network. 
 
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 
among those covered under this benefit if they are received from participating providers. Therefore, we decided 
that the Plan does not have to pre-approve a comprehensive oral evaluation.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a white glass with metal crown (D2751). 
 
You asked the Plan to pre-approve a white glass with metal crown. You say that this dental care is necessary 
for your condition. The Plan denied your request. The Plan says that it is not medically necessary to replace the 
cap on the tooth according to the medical records. 
 
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 has denied coverage for this dental care referring 
specifically to X-rays of your mouth. These X-rays and other medical records from your dentist were not 
provided. We sent a request to the Plan specifically requesting these medical records as well as clarification of 
what supplemental dental plan you are enrolled in. A response to our request for information was not returned 
to us. The Plan has not made reasonable and diligent efforts to forward necessary information required for a 
medical review. Therefore, we decided that the Plan has to pre-approve a white glass with metal crown 
(D2751).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray angiography of the abdomen (75726) and of 
additional vessels (75774) provided on June 6, 2021. 
 
You asked the Plan to pay for X-ray angiography services. You say that you have provided medical records to 
support the services at issue. 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, we have confirmed that codes 
75726 and 75774 are column II codes to column I code 37244. This claim has not been billed with appropriate 
modifiers to bypass the edits. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for an X-ray angiography of the abdomen (75726) and 
of additional vessels (75774) provided on June 6, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low level light therapy. 
 
You asked the Plan to pre-approve low level light therapy. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices and any related 
accessories are not a covered benefit. 
 
We looked at the file and Medicare rules. Review of the file shows that you are requesting low level light 
therapy for the enrollee. This is strictly not covered. Based on this information, we decided that Medicare rules 
for coverage of low level light therapy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve low level light therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shank foot system (L5987) and axial rotation unit 
(L5984). 
 
You asked the Plan to pre-approve a shank foot system and axial rotation unit. You say that the enrollee's 
current foot does not function properly. The Plan denied your request. The Plan says the enrollee's current foot 
is still within warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to irreparable 
wear takes into consideration the reasonable useful lifetime of the equipment. The reasonable useful lifetime of 
durable medical equipment is determined through program instructions, but in no case can it be less than 5 
years. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not 
actual replacement) for medically necessary equipment owned by the beneficiary.  
We looked at the file and Medicare rules. The enrollees current foot system was provided in January 2020, 
less than 5 years ago. Based on this information, we decided that Medicare rules for coverage of a shank foot 
system and axial rotation unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a shank foot system (L5987) and axial rotation unit (L5984).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274), comprehensive oral evaluation 
(D0150), and panoramic x-rays (D0330) provided on March 28, 2022. 
 
You asked the Plan to pay for the bitewing x-rays, comprehensive oral evaluation, and panoramic x-rays. The 
Plan denied your request. The Plan says the enrollee's benefits for these services have been satisfied and the 
frequency limitations have 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, bitewing x-rays are limited to 1 set per 
calendar year. The record shows that the enrollee received bitewing x-rays (D0274) on January 7, 2022 and the 
enrollee's bitewing x-rays benefit has been exhausted. The Plan contract says that comprehensive oral 
evaluation is limited to 1 procedure code every 3 calendar years, and full mouth or panoramic x-rays share a 
frequency limitation of 1 procedure code every 5 calendar years. The record shows that the enrollee received a 
comprehensive oral evaluation (D0150) and a complete series of intraoral x-rays (D0210) on June 18, 2020 and 
the enrollee's comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274), comprehensive oral 
evaluation (D0150), and panoramic x-rays (D0330) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided by a network provider on 
November 8, 2021. 
 
You asked the Plan to pay for the consultation (D9310). You say that your teeth were not touching, and you 
were unable to chew food properly. The Plan denied your request. The Plan says the service was 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 consultation (D9310) was not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) provided by a network provider on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 23) provided by a network provider 
on February 17, 2022. 
 
You asked the Plan to pay for the extractions (D7210 x23). You say that the dentist charged the incorrect dental 
plan, instead of your independent plan. The Plan denied your request. The Plan says the services were 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 extractions (D7210 x23) are not 
among those covered under this benefit. The record shows you were enrolled in the Plans mandatory 
supplemental dental coverage. Therefore, we decided that the Plan does not have to pay for the extractions 
(D7210 x 23) provided by a network provider on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), and surgical extraction (D7210) provided on March 28, 2022 by an out-of-network 
(OON) provider. 
 You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
surgical extraction. You say that you do not agree with the Plan's denial. The Plan denied your request. The 
Plan says there is no coverage for services that are rendered by an OON 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and surgical extraction 
(D7210) provided on March 28, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and the hot or cold 
packs therapy (97010) provided on August 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012) and the hot or cold packs therapy 
(97010) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 7, 2022. 
 
You asked the Plan to pay for the core buildup. You say that it was your understanding that the crown would be 
covered with no copay. The Plan denied your request. The Plan says this 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 the core 
buildup, including any pins when required (D2950) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
panoramic radiographic image (D0330) provided February 21, 2022. 
 
You asked the Plan to pay for the limited oral exam and panoramic x-ray. You say that these services should be 
processed under your emergency room benefit. The Plan denied your request. The Plan says you have exceeded 
the frequency limits 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 limited 
oral exam once per calendar year and the panoramic x-ray once every 5 calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered February 21, 2022, and a complete series of x-rays was previously covered on June 23, 
2021. Based on this information, we decided that the Plan's frequency limits for coverage of the limited oral 
exam and panoramic x-ray have been exceeded. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation - problem focused (D0140) and panoramic radiographic image (D0330) provided 
February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic image and core buildup, including any pins on 
January 24, 2022 to February 7, 2022. 
 
You asked the Plan to pay for a panoramic image and core buildup, including any pins. You say that you would 
like to appeal the denial of the claim. The Plan denied your request. The Plan says a panoramic image (D0330) 
is included once every three years, but the member received this service on June 3, 2020. Core buildup (D2950) 
isn't covered under the member's 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 panoramic image 
(D0330) is included once every three years but core buildup (D2950) isnt covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a panoramic image and core buildup, including 
any pins on January 24, 2022 to February 7, 2022.
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) provided on 
February 7, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you should not be held 
responsible for the charges. The Plan denied your request. The Plan says your benefits for this service have 
been satisfied and the frequency limitation 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, full mouth or panoramic x-rays share a 
frequency limitation of 1 procedure code every 5 calendar years. The record shows that you received a 
complete series of intraoral x-rays (D0210) on February 20, 2019 and your full mouth or panoramic x-rays 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of 
intraoral x-rays (D0210) provided on February 7, 2022.