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

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), and a diagnostic service 
consultation (D9310) provided by a participating provider on October 27, 2020, to November 4, 2020. 
 
You asked the Plan to pay for panoramic imaging and a diagnostic service consultation. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says D0330 has already been 
exhausted. The Plan says that D9310 is not a covered dental 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. The Plan covers one set of 
panoramic imaging every five year. A diagnostic service consultation is not a covered benefit. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0330 was previously provided 
on October 7, 2020. Based on this information, we decided that the Plan's rules for coverage of panoramic imaging have not been met. Z diagnostic service consultation is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for panoramic imaging (D0330), and a diagnostic service consultation 
(D9310) provided by a participating provider on October 27, 2020, to November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical radiographic images (D0220 and D0230) 
provided on November 1, 2021. 
 
You asked the Plan to pay for dental codes D0220 and D0230. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says periapical radiographic images 
are limited to one procedure code per calendar year. The Plan says that this benefit was exhausted for date of 
service January 19, 2021, where you received a periapical radiographic image (D0220) that the Plan paid for. 
 
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. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan contract says that periapical 
radiographic images are limited to one procedure code per calendar year.  
 
The file shows that this benefit was exhausted for date of service January 19, 2021, where you received a 
periapical radiographic image (D0220) that the Plan paid for. Therefore, we decided that the Plan does not have 
to pay for the periapical radiographic images (D0220 and D0230) provided on November 1, 2021.  
 
Your complaint about not receiving the service at issue is not a valid appeal 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: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for services billed under code 70450.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating
the services were medically necessary. The Plan requested a reopen and stated that the issue was not medical
necessity but that the claim was coded inappropriately and could not be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
appropriate modifiers. A National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between codes 70496 and 70450. In this case, we have confirmed that this claim was not billed with the
appropriate modifier to bypass the edit. Therefore, we decided that the Plan does not have to pay for computed
technology services provided to the enrollee on April 21, 2021 and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 20, 2021. 
 
You asked the Plan to pay for the dental service. You say that you verified with your insurance that the 
provider was in network. You also say that you did everything correct on your part and the services should be 
covered. The Plan denied your request. The Plan says the frequency limit 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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for the limited oral 
evaluation that you received on October 20, 2021, by a different provider. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
November 17, 2021. 
 
You asked the Plan to pay for the fluoride varnish. You say that you were given incomplete information about 
network dentists with your plan. The Plan denied your request. The Plan says a one-time exception has been 
granted to process the claims from this date-of-service as in-network however the fluoride varnish 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 
topical application of fluoride varnish (D1206) provided November 17, 2021.  
 
Your complaint about the Plan having out-of-date information and a plan representative providing incomplete 
or inaccurate information is not a valid appeal 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
sacroiliac joint fusion and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is scheduled/approved for a sacroiliac joint fusion. The record 
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or 
more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on August 5, 2021. 
 
You asked the Plan to pay for code 81455. 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 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 code 81455 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 (81455) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and 
extractions (D7210 x28). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation, and extractions. You say that the services 
are medically necessary, and you cannot afford to pay out-of-pocket. The Plan denied your request. The Plan 
says the services at issue are not covered unless they are performed by a participating general dentist. Dental 
services performed by an oral surgeon are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, and extractions have not been met. Specifically, the services at 
issue are not covered unless they are performed by a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and extractions (D7210 x28).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 16, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were not billed as required by regulations. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, the CPT Code Manual definition of code 99152 is moderate 
sedation services provided by the same physician or other qualified health care professional performing the 
diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained 
observer to assist in the monitoring of the patient's level of consciousness and physiological status. We find that 
CPT code 99152 is not supported in the medical record. Specifically, the records do not include the presence of 
an independent trained observer.  
 
We looked at the file and the rules. We find that code 99153 is a technical component only code. This code is 
not payable as billed. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 5, 2021, to September 26, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says hospice was elected on September 5, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 5, 2021, to September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported retainer for porcelain fused to metal 
for fixed partial denture (D6069) for tooth # 7, and implant supported retainer for fixed partial denture (D6076) 
for teeth # 8 and 6. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says the requested services are not covered under the 2021 Evidence of 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve abutment supported retainer for porcelain fused to metal for fixed partial denture (D6069) for tooth # 7, and implant supported retainer for fixed partial denture (D6076) for teeth # 8 and 6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), 
chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory 
nerves, bilateral (64615), and office or other outpatient visit for the evaluation and management of a new 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making (99205) provided October 15, 2021. 
 
You asked the Plan to pay for the panoramic x-ray, chemodenervation of facial muscles with botulism toxin 
and dental office visit. You say that the services should be covered under your medical coverage. The Plan 
denied your request. The Plan says these services are not covered under your dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
The services you are asking the Plan to pay for were provided in a dental office and 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 the panoramic radiographic image (D0330), chemodenervation of muscle(s); muscle(s) innervated by facial, 
trigeminal, cervical spinal and accessory nerves, bilateral (64615), and office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making (99205) provided October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic, porcelain/ceramic crown (D6245) for tooth #14 and a 
retainer crown (D6740x2) for tooth #12 and tooth #15. 
 
You asked the Plan to pre-approve a pontic, porcelain/ceramic crown and a retainer crown. You say that the 
enrollee is missing only one tooth that needs to be replaced. The post/build up and three-unit bridge replaces 
what the enrollee already presented with for decades. The Plan denied your request. The Plan says that the 
services are denied because the submitted narrative fails to indicate or support any specific physical or 
psychological condition(s) for using removable prosthesis. The Plan also says the requested services are not 
medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We 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 a pontic, porcelain/ceramic and a 
retainer crown. Our reviewer says that the service is medically necessary. Our physician reviewer found the 
documentation provided meets the criteria for coverage for a fixed bridge replacing the defective bridge 
utilizing teeth #'s 12 and 15 as abutment retainers (D6740) and a pontic (D6245) replacing missing tooth #14. 
 
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 a pontic, porcelain/ceramic and a retainer crown have been met. Therefore, we 
decided that the Plan has to pre-approve a pontic, porcelain/ceramic crown (D6245) for tooth #14 and a retainer 
crown (D6740x2) for tooth #12 and tooth #15.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on September 17, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental work 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 
periodontal maintenance (D4910) provided by a participating provider on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
November 12, 2021. 
You asked the Plan to pay for code 70450. 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the Computed tomography (CT) scan (70450) provided on 
November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam capture and interpretation for tooth #27 
(D0367), a surgical placement of an implant body for tooth #22 (D6010) and an autogenous connective tissue 
graft procedure for tooth #22 and #27 (D4273x2). 
 
You asked the Plan to pre-approve a cone beam, a surgical placement of an implant body and two autogenous 
connective tissue graft procedures. You say that you have a $1,000 allowance with your Plan, and you have 
$958 remaining. You also say you are having several problems with your dentures which are causing issues for 
you to eat. The Plan denied your request. The Plan says the requested services are not listed and therefore 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. 
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 
cone beam capture and interpretation for tooth #27 (D0367), a surgical placement of an implant body for tooth 
#22 (D6010) and an autogenous connective tissue graft procedure for tooth #22 and #27 (D4273x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided November 15, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you were given incomplete 
information about network dentists with your plan. The Plan denied your request. The Plan says a one-time 
exception has been granted to process the claims from this date-of-service as in-network however the complete 
series of x-rays 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 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 intraoral - complete series of radiographic images (D0210) provided November 15, 2021.  
 
Your complaint about the Plan having out-of-date information and a plan representative providing incomplete 
or inaccurate information is not a valid appeal 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), unspecified preventive 
services (D1999 x 2), bitewing x-rays (D0272), periapical x-rays (D0220 x 2), core build up (D2950), and 
crown (D2740) provided from September 16, 2021, to October 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have a maximum benefit of $2,000. You 
say that only $157 has been used. You also say that you need help paying this bill. The Plan denied your 
request. The Plan says the claims processed correctly. 
 
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 and 1 periapical x-ray, and 1 bitewing 
x-ray is covered, the frequency limits have been exceeded. The record shows that the Plan paid for a periapical 
x-ray and bitewing x-rays that you received on May 24, 2021. Additionally, limited oral evaluation, unspecified 
preventive services, core build up, and crown are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140), unspecified preventive 
services (D1999 x 2), bitewing x-rays (D0272), periapical x-rays (D0220 x 2), core build up (D2950), and 
crown (D2740) provided from September 16, 2021, to October 27, 2021.