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

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), surgical extraction (D7210), 
and conscious sedation services (D9239, D9243) provided on January 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that the services 
would 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 panoramic x-ray, surgical 
extraction, and conscious sedation services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330), surgical extraction (D7210), and 
conscious sedation services (D9239, D9243) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral hygiene instructions (code D1330), comprehensive 
oral evaluation (code D0150), and panoramic images (codes D0330 and D0350) provided on February 10, 2022. 
 
You asked the Plan to pre-approve dental services. You say that this was your first visit to a dentist in 2022 and 
you have not been to a dentist in over a year. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because these services are not covered by the Plan's dental benefits or 
they are covered but the coverage benefit 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 Plan's coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation once every 3 calendar years and complete or panoramic films once every 5 
calendar years. The Plan does not cover oral hygiene instructions.  We looked at this the file, the Plan's rules, 
and Medicare rules. You previously received a comprehensive oral examination and complete series of images on March 28, 2020; therefore, the benefits for both of these services were exhausted on February 10, 2022. Additionally, oral hygiene instructions are not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve oral hygiene instructions (code D1330), comprehensive oral evaluation (code D0150), and panoramic images (codes D0330 and D0350) provided on 
February 10, 2022.
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 February 10, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you cannot afford the cost of this service. The 
Plan denied your request. The Plan says this service is not covered under your 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 core 
buildup, including any pins when required (D2950) provided February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
December 7, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the maximum benefit allowance amount has already been met and 
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 up to a $350 
maximum allowance benefit amount for covered dental benefits.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a non-contracted provider on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, and 81301) provided 
on September 20, 2021. 
 
You asked the Plan to pay for codes 81206, 81275, 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, and 81301) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) provided January 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the dental extraction provided OON. You say that this 
dentist is in the same office as a network provider and no one informed you that this oral surgeon is OON. The 
Plan denied your request. The Plan says the cost sharing applied correctly to the OON service. The Plan 
additionally states that they did not find any calls to customer service about benefits, network providers or cost-
sharing prior to the service being rendered. 
 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 contracts says that if 
you choose to see an OON dentist you might be billed by that provider for any amount greater than what the 
Plan pays, even for services listed as $0 copayment. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that they have covered 
the full allowed amount for this service. You have been asked to pay the amount greater than what the Plan 
pays for the OON service. This means you have been asked to pay the correct amount based on your contract 
with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided January 14, 2022, by an out-of-network (OON) provider.  
 
Your complaint about not feeling adequately informed of the provider's network status and the fact that there 
are providers with differing network statuses practicing in the same office are not valid appeals 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS) (1 unit of
90867 - TMS Mapping, and 35 units of 90868 - TMS Subsequent Treatments ).
You asked the Plan to pre-approve TMS. You say that the service is medically necessary. The Plan denied your
request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must
be met for coverage of this service.
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 TMS. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the patient did not show documentation of
electroconvulsive treatment (ECT) or transcranial magnetic stimulation (TMS) in the past. The patient has no
clear documentation of recent symptoms, improvement with psychotherapy or any recent use of medication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to
pre-approve Transcranial Magnetic Stimulation (TMS) (1 unit of 90867 - TMS Mapping, and 35 units of 90868
- TMS Subsequent Treatments ).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), complete series x-ray (D0210), and sales tax (D9985) provided on February 20, 2022, by the out of 
network dentist. 
 
You asked the Plan to pay for the dental services. You say that you were misinformed by multiple plan 
representatives that the provider in this case was in network. You say that you would not have gone to this 
provider had you been told they were not in network. You also say that you are on a fixed income. The Plan 
denied your request. The Plan says the claim denied 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 dental services are not among those 
covered under this benefit when received out of network. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210), and 
sales tax (D9985) provided on February 20, 2022, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the recement crown (D2920), periapical 
x-ray (D0220), sales tax (D9985), periodontal maintenance (D4910), bitewing x-rays (D0274), and oral exam 
(D0120) provided from January 14, 2022, to February 11, 2022, by the out of network dentist. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you were notified that your 
plan had added dental coverage. You say that you thought that your dentist would still be in network since you 
had this plan before turning 65. You also say that you would like this services to be covered as in network. The 
Plan denied your request. The Plan says the claim processed correctly. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out of network dentists may bill you 
for any amount greater than what the plan pays the provider. This is a contractual obligation you agreed to 
when you enrolled in the Plans dental coverage. Additionally, sales tax is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the recement crown 
(D2920), periapical x-ray (D0220), sales tax (D9985), periodontal maintenance (D4910), bitewing x-rays 
(D0274), and oral exam (D0120) provided from January 14, 2022, to February 11, 2022, by the out of network 
dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
27, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that it was indicated that additional 
cleanings would be covered for patients who have received scaling and root planing, and the provider had no 
reason to believe this would not apply to your specific case. The Plan denied your request. The Plan says the 
contract provides benefits for this procedure twice in a benefit period. 
 
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, routine preventive teeth cleanings are 
limited to a maximum of 2 per calendar year. The record shows that you received periodontal maintenance 
services (D4910) on March 29, 2021, and June 30, 2021 and your routine preventive teeth cleaning benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown. We decided that the Plan does not have to pre-approve 
clinical crown lengthening.  
 You asked the Plan to pre-approve a crown and clinical crown lengthening. You say that these services are 
necessary. The Plan says that clinical crown lengthening is not covered by your dental benefit, and the crown is 
not medically necessary as this tooth has either a large cavity or poor bone support. The prognosis for a crown 
on tooth #11 is poor, and therefore the requested restoration is not medically necessary. 
 
We decided that the Plan has to pre-approve the crown.  
 
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. Specifically, this crown is listed as an eligible service in the Plans Dental Office 
Reference Manual. The Plan denied coverage of this service due to medical necessity; however, the Plan did 
not forward the medical records and/or x-rays used to reach this decision to us for review. Without this 
information, the Plans denial cannot be substantiated. Therefore, we decided that the Plan has to pre-approve a 
crown (D2752) for tooth #11.  
 
We also decided that the Plan does not have to pre-approve clinical crown lengthening. 
 
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 
clinical crown lengthening (D4249). 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from  
October 14, 2021, through October 19, 2021 and October 28, 2021, through November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the SNF care provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 pay for the SNF care. Our reviewer says that the 
skilled nursing facility care provided was not medically necessary. Our physician reviewer found that at the 
time of re-admission, the member required skilled care due to medical illness and weakness. From October 14, 
2021, through October 19, 2021 and October 28, 2021, through November 12, 2021, the member did not have 
skilled nursing needs. The member did not have any parental medications, complex wound care or nutrition 
given via a feeding tube. The member received skilled care and improved; however, her function was stable 
and at baseline. The member was medically stable and did not require further skilled care.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) care provided from October 14, 2021, through October 19, 2021 
and October 28, 2021, through November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291-25 billed for date of service 
September 15, 2021. 
 
You asked the Plan to pay for procedure code 99291-25. You say that this code should be paid. The Plan 
denied your request. The Plan says this procedure code is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 99291 is Critical care services in addition to services 
performed with a global day period. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99291-25. Our reviewer says that procedure 
code 99291-25 is not supported in the medical record. Our reviewer found the documentation does not include 
documentation of critical care services. The documentation describes evaluation and management services and 
decision for further treatment on a different date other than the evaluation and management service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99291-25 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99291-25 billed for date of service September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve treatment (D3120), a crown (D2740), and a core build 
up (D2950) for tooth #5 provided by a participating provider on February 28, 2022. 
 
You asked the Plan to pay for nerve treatment, a crown, and a core build up. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the x-rays that were provided were not clear. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of nerve treatment (D3120), a crown 
(D2740), and a core build up (D2950) for tooth #5 provided by a participating provider on February 28, 2022. 
have been met. Legible dental x-rays were not provided. Therefore, we decided that the Plan does not have to 
pay for nerve treatment (D3120), a crown (D2740), and a core build up (D2950) for tooth #5 provided by a 
participating provider on February 28, 2022.