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

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473), the removal 
of torus palatinus (D7472), and non-intravenous conscious sedation (D9248), provided by a participating 
provider. 
 
You asked the Plan to pre-approve dental services. You say that you do not understand why this is not covered. 
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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus mandibularis (D7473), the removal of torus palatinus (D7472), and non-intravenous conscious 
sedation (D9248), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture resin base (D5211), a 
mandibular partial denture resin base (D5212), a maxillary partial denture (D5213), and a mandibular partial 
denture (D5214), provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested dental work is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture resin base (D5211), a mandibular partial denture resin base (D5212), a maxillary 
partial denture (D5213), and a mandibular partial denture (D5214), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation - per site 
(CPT code D7953), interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular 
(D5821) and a dental extraction (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you have a tooth in the front that has 
completely broken, and you are unable to eat anything/chew, and this is causing weight loss on your end and 
pain/suffering. The Plan denied your request. The Plan says the services are not a covered benefit under 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 pre-approve bone 
replacement graft for ridge preservation - per site (CPT code D7953), interim partial denture (including 
retentive/clasping materials, rests, and teeth), mandibular (D5821) and a dental extraction (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393) provided by an out-of-
network provider on April 18, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the plan to pay for this. 
The Plan denied your request. The Plan says covered dental services must be provided by a participating 
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. The Plan covers a resin-based 
composite when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to 
pay for a resin-based composite (D2393) provided by an out-of-network provider on April 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 14, 2022, 
to March 19, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
had no skilled therapy or skilled nursing service needs, and did not meet the Medicare coverage guidelines. 
 
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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 14, 2022, to March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
(D3950) for teeth # 19 and 20. 
 
You asked the Plan to pre-approve the dental services. You say that you do not have money to pay for these 
services. You also say that you have dual coverage that is supposed to pay and cover for these services. The 
Plan denied your request. The Plan says the requested 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 requested canal preparation and 
fitting of preformed dowel or post for teeth # 19 and 20 are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
(D3950) for teeth # 19 and 20.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 26, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
you believe this claim was denied due to untimely filing. The Plan denied your request. The Plan says it is not 
responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on July 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
on July 26, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the bone marrow aspiration (20939). We decided that the Plan does not 
have to pay for the laminectomy, facetectomy and foraminotomy (63047 and 63048).  
 
You asked the Plan to pay for the bone marrow aspiration (20939) and laminectomy, facetectomy and 
foraminotomy (63047 and 63048). You say that codes 63047 and 63048 were separate necessary procedures 
that are documented in the operative notes and are separately reimbursable. You say that 20939 was a 
necessary procedure that is covered under CMS guidelines and the claim should be reconsidered for payment. 
The Plan says that procedure code 20939 is not supported by the medical records submitted. The Plan also says 
that procedure code 63047 is considered inclusive to CPT code 22633 and procedure code 63048 is considered 
inclusive to CPT code 22634. 
 
We decided that the Plan has to pay for the bone marrow aspiration (20939).  
 
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 the bone marrow aspiration. Our reviewer says that medical 
documentation supports the use of procedure code 20939. Our reviewer found that the provider documented the 
use and aspiration of bone marrow. Therefore, we decided that the Plan has to pay for the bone marrow 
aspiration (20939).  
 
We also decided that the Plan does not have to pay for the laminectomy, facetectomy and foraminotomy 
(63047 and 63048). 
 
In this case, we have confirmed that code 63047 is a column II code to column I code 22633; however, 63047 
was billed with a modifier. Our reviewer found that the documentation does not support the use of procedure 
code 63047. In addition, code 63048 is a column II code to column I code 22634. Procedure code 63048 was 
not billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria for procedure codes 63047 and 63048 have not been met. Therefore, we decided that the Plan does not 
have to pay for the laminectomy, facetectomy and foraminotomy (63047 and 63048). 
 
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 pre-approve maxillary partial dentures (D5213) and mandibular 
partial dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not fit properly, and the 
denture adjustments did not help. 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 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 items or services was exhausted on date of service April 11, 2018. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial dentures (D5213) and 
mandibular partial dentures (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on March 12, 2022, to March 
24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON acupuncture services. You say that you would like to appeal this denial. 
The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for acupuncture services provided on March 12, 2022, to March 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services in an ambulatory surgical center provided 
to the enrollee on February 4, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be reviewed based on the patient's 
condition during the time the service was rendered. The Plan denied your request. The Plan says a corrected 
claim form is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly on the 
appropriate claim form. 
 
These types of services shouldn't be billed on a UB04 claim form. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services in an ambulatory surgical center provided to the enrollee on February 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a root canal obstruction on tooth #29 
(D3331) provided on December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told the insurance covered everything. 
The Plan denied your request. The Plan says treatment of a root canal obstruction (D3331) is not covered by 
your routine 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. 
 
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 
treatment of a root canal obstruction on tooth #29 (D3331) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete dentures (D5110) and mandibular partial 
dentures (D5214) provided on May 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was in-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. 
 
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, 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 maxillary complete dentures (D5110) and mandibular partial dentures (D5214) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional metal substructure to acrylic full denture 
(D5876) provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the plan to approve these 
services. The Plan denied your request. The Plan says the requested 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 pre-approve 
additional metal substructure to acrylic full denture (D5876) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials (D3431). 
 
You asked the Plan to pay for biologic materials. You say that you need this service to have a root canal done. 
The Plan denied your request. The Plan says biologic materials (D3431) are not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 biologic 
materials (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210), provided by a participating provider on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is the first time you are using this plan this 
year. 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 March 23, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral imaging (D0210), provided by a participating provider on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemotherapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you would like to continue 
treatment with this provider. The Plan denied your request. The Plan says a network provider can care for your 
medical problem. 
 
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 
the chemotherapy to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that your upper denture has cracked, 
and you were advised it cannot be fixed. You also say that you cannot eat without your upper denture. 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 May 10, 2018. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided March 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that the OON liability was applied correctly. 
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 the periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided 
March 17, 2022, by an out-of-network (OON) provider.  
 
Your complaint about the potential difference in the allowed amount from year to year 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.