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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral - 
complete series of radiographic images (D0210) provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you don't feel responsible for this bill and wish 
to appeal the $285 invoice. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), and intraoral - complete series of radiographic images 
(D0210) provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic pulpotomy (D3220) provided on March 2, 
2022. 
 
You asked the Plan to pay for D3220. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental service is 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 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 
therapeutic pulpotomy (D3220) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7140), sedation (D9222 and D9223), 
and to pay for the excision of torus mandibularis (D0001) for tooth #21, #22, #23, #24, #25, #26, #27, #28, and 
#31 provided by an out-of-network provider on October 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to collect the balance of 
the amount that is still owed. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Also, the denial of payment for the excision of torus mandibularis is correct because it is 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 Plans coverage rules apply in this case. You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
excision of torus mandibularis is not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay more for the extractions (D7140), sedation (D9222 and D9223), and to pay for the 
excision of torus mandibularis (D0001) for tooth #21, #22, #23, #24, #25, #26, #27, #28, and #31 provided by 
an out-of-network provider on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and a core build-up (D2950), 
provided on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with these charges. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a crown (D2740) and a core build-up 
(D2950), provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
a cleaning (D1110), and the application of fluoride (D1206) provided by an out-of-network provider on 
September 12, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you should only be paying about 25% of 
the bill and the Plan paid the incorrect amount. The Plan denied your request. The Plan says the proper cost 
share was applied. 
 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. 
 
You have been asked to pay 50% of the fee that was charged for the dental services from an out-of-network 
provider. The total charged amount for the periodic oral evaluation was $66 with a coinsurance of $33 ($66 
charged x 50% coinsurance). The total amount charged for the bitewings was $76 with a coinsurance of $38 
($76 charged x 50% coinsurance). The total amount charged for the cleaning was $112 with a coinsurance of 
$56 ($112 charged x 50% coinsurance). The total amount charged for the application of fluoride was $40 with 
a coinsurance of $20 ($40 charged x 50% coinsurance). The total coinsurance amount was $147 ($33 
coinsurance + $38 coinsurance + $56 coinsurance + $20 coinsurance). Also the records show you are not 
enrolled in a preferred provider organization (PPO) 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 more for 
a periodic oral evaluation (D0120), bitewings (D0274), a cleaning (D1110), and the application of fluoride 
(D1206) provided by an out-of-network provider on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim implant crown (D6085 x2) provided on August 9, 
2022. 
 
You asked the Plan to pay for the interim implant crown. You say that you called the Plan twice and they were 
aware the doctor was not in-network. You also say you are asking for 30% of the $3,200 as the Plan knew you 
called about crowns and implants. The Plan denied your request. The Plan says this service is not covered 
under the benefit package. 
 
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 an interim 
implant crown (D6085 x2) provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive exam (D0150) and full mouth/complete x-ray 
set for evaluation of the teeth and mouth (D0210) provided on August 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2020. 
Therefore, we decided that the Plan does not have to pay for comprehensive exam (D0150) and full 
mouth/complete x-ray set for evaluation of the teeth and mouth (D0210) provided on August 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of femoral shaft fracture with 
plate/screws, with or without cerclage coded 27507 provided on September 21, 2022. 
 
You asked the Plan to pay for the open treatment of femoral shaft fracture with plate/screws, with or without 
cerclage. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are not supported. 
 
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 27507 is open treatment of femoral shaft fracture with 
plate/screws, with or without cerclage. 
 
We find that CPT code 27507 is not supported in the medical record. Specifically, operative report did not 
include documentation of an open treatment of femoral shaft fracture with plate/screws, with or without 
cerclage; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the open treatment of femoral shaft fracture with plate/screws, with or without cerclage have not 
been met. Therefore, we decided that the Plan does not have to pay for the open treatment of femoral shaft 
fracture with plate/screws, with or without cerclage coded 27507 provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 8, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dentist visit was an emergency and was not a 
routine visit and the service should be covered. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of July 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete mandibular denture (D5751) provided on 
November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe this should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 28, 2022 with 
the a realignment of a complete maxillary denture. Therefore, we decided that the Plan does not have to pay for 
a reline complete mandibular denture (D5751) provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the thoracic spine 
(72070), and the x-ray exam of the lumbar spine (72100) provided on October 12, 2022. 
 
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 covered by Medicare or 
the Plan. 
 
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 office visit (99202), x-ray exam of the thoracic spine (72070), and the 
x-ray exam of the lumbar spine (72100) provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower 
denture (D5140), extractions (D7140), and alveoloplasty (D7310) for tooth #6, #7, #8, #10, #11, #15, #20, #21, 
#22, #23, #24, #25, #26, #27, #28, and #29 provided by an out-of-network provider on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told you had to stay in-network 
to get dental services and the initial salesman should have told you. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an immediate upper denture (D5130), an immediate lower denture (D5140), extractions (D7140), 
and alveoloplasty (D7310) for tooth #6, #7, #8, #10, #11, #15, #20, #21, #22, #23, #24, #25, #26, #27, #28, and 
#29 provided by an out-of-network provider on June 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29916 billed for date of service September 
27, 2022. 
 You asked the Plan to pay for procedure code 29916. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 29916 is bundled into payment for code 29915. 
 
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 code 29916 
is a column II code to column I code 29915. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 29916 billed for date of service September 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you wanted a second opinion and were charged 
$300. You also say that you were informed that you would not be reimbursed because the provider is out-of-
network. 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 September 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the octreotide injection provided on May 17, 2022. 
 
You asked the Plan to pay for the octreotide injection. You say that you are appealing with a waiver of liability 
(WOL) included. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the octreotide injection 
provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that the recommended network provider cannot 
render adequate care. The Plan denied your request. The Plan says network providers are available to render 
necessary care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 19, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision to the gastrojejunostomy (43633) and repair of 
the hiatal hernia (43281) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve revision to the gastrojejunostomy and repair of the hiatal hernia to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
revision to the gastrojejunostomy (43633) and repair of the hiatal hernia (43281) to be provided by an out-of-
network (OON) provider.