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

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) and 
a guided tissue regeneration (D4266), provided by a participating provider on July 28, 2021. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation and a guided tissue regeneration. 
You say that you would like reimbursement. You say that you had to have your teeth fixed. The Plan denied 
your request. The Plan says the rendered 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 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 a bone replacement graft for ridge preservation 
(D7953) and a guided tissue regeneration (D4266), provided by a participating provider on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want to appeal the services. The Plan 
denied your request. The Plan says the services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and 
periapical x-ray 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) and periapical x-ray (D0220) provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external urine removal system. 
 
You asked the Plan to pre-approve the external urine removal system. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the requested items are not reusable and are non-
covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve an external urine removal 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220), a core build-up (D2950), 
endodontic therapy (D3320), and a diagnostic service consultation (D9310), provided by an out-of-network 
provider on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the provider was out-of-
network. 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. The Plan says that D9310 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 Plan's 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, D0220, D2950 and D3320 are not covered under this 
benefit when received from an out-of-network provider. D9310 is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for intraoral imaging (D0220), a core build-up (D2950), endodontic therapy 
(D3320), and a diagnostic service consultation (D9310), provided by an out-of-network provider on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult and treatment of a broken cap provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the requested items and services are not covered when 
received by an oral surgeon. 
 
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 when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a consult and treatment of a broken cap provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated abutment (D6056) and abutment supported 
porcelain fused to metal crown (D6059) provided on May 3, 2022. 
 
You asked the Plan to pay for prefabricated abutment (D6056) and abutment supported porcelain fused to 
metal crown (D6059). You say that the dental services should be covered. The Plan denied your request. The 
Plan says this service is not covered under your 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 dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
prefabricated abutment (D6056) and abutment supported porcelain fused to metal crown (D6059) provided on 
May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and an abutment supported 
crown (D6059) provided by a participating provider. 
 
You asked the Plan to pre-approve a custom abutment and an abutment supported crown. You say that you 
need these implants in order to eat. The Plan denied your request. The Plan says the requested 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 a 
custom abutment (D6057) and an abutment supported crown (D6059) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported retainers (D6071), custom fabricate 
abutment (D6057), and pontics (D6242), provided by a participating provider. 
 
You asked the Plan to pre-approve abutment supported retainers, custom fabricate abutment, and pontics. You 
say that if you do not have these services done, you will have no front teeth. The Plan denied your request. The 
Plan says the requested 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 
abutment supported retainers (D6071), custom fabricate abutment (D6057), and pontics (D6242), provided by a 
participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (code 71045-26) provided on October 19, 
2021. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 22, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the chest x-ray (code 71045-26) provided on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute-care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be currently still unstable and requires short-term 
additional acute-care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) 
provided on June 2, 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 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction of 
an erupted tooth or exposed root (D7140) provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code G0463. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code G0463 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0463 is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0463 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0463 billed for date of service March 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 12, 2021, to September 10, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP 
claim was submitted on March 22, 2022. This means the RAP was submitted after five calendar days after the 
last date of service billed. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from August 12, 2021, to September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
re-cement or re-bond crown (D2920), and resin-based composite (D2391) provided from March 24, 2022, to 
April 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your dentist was OON. 
The Plan denied your request. The Plan says the dental services were received from an OON 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 Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested services are not covered under this benefit when 
received from an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120), prophylaxis (D1110), re-cement or re-bond crown (D2920), and resin-based composite 
(D2391) provided from March 24, 2022, to April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided on May 1, 2022, and crowns on tooth #21 and 22 (D2740) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised by the dentist that you were 
covered at 100%. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 Plan's 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 a comprehensive oral evaluation and intraoral x-rays was exhausted on date of service 
May 2, 2022. The record also shows your benefit for crowns on tooth #21 and 22 was exhausted on date of 
service June 30, 2017. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and intraoral x-rays (D0210) provided on May 1, 2022, and crowns on tooth #21 and 22 
(D2740) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete intraoral x-rays (D0210) and the 
comprehensive oral evaluation (D0150) provided by a network provider on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an infection and were in a lot of pain. 
You say you needed these services and the treatment helped. The Plan denied your request. The Plan says your 
benefit for the requested services have 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 benefits for the requested services were exhausted on date of service September 16, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete intraoral x-rays (D0210) and the 
comprehensive oral evaluation (D0150) provided by a network provider on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were unaware that 
this claim had been denied because you did not have anyone to read your mail to you. 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 Plan's 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 annual allowance for the requested item or service was exhausted on date of service July 15, 2021.  
 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 Plan's 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 April 17, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 provided on September 12, 2021. 
 
You asked the Plan to pay for procedure code 99239. You say that the evaluation and management service was 
warranted and considered medically necessary. You say that the coding is correct, and the attached medical 
records support the claim as originally billed. The Plan denied your request. The Plan says procedure code 
99233 has been overturned and procedure code 99239 is not supported by the medical records submitted. 
  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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document 
discharge management services of more than 30 minutes as required by the CPT code billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99239 provided on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enamel microabrasion (D9970). 
 
You asked the Plan to pay for the dental services. You say that the provider over charged you and you would 
like the Plan to pay for the service. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the enamel microabrasion 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. 
 
  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 
enamel microabrasion (D9970).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing (81404) provided on June 
25, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Local Coverage Article A58797 provides a list of 
non-covered codes for cardiovascular genetic testing.  
 
We looked at the file and Medicare rules. Per LCA A58797, code 81404 is non-covered for cardiovascular 
genetic testing. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic testing 
(81404) provided on June 25, 2021.