Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of the pelvis (72170) provided on November 5, 2021. 
 
You asked the Plan to pay for the X-ray of the pelvis. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
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 72170 
is a column II code to column I code 72190. 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 X-ray of the pelvis (72170) provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), provided on September 15, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that the service should be covered. The Plan denied 
your request. The Plan says you got the service from a provider who chose not to receive Medicare funds. This 
means they're on the Medicare opt-out list. 
 
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 
prophylaxis (D1110), provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the form fitting conductive garment for delivery of TENS or 
NMES (CPT code E0731) provided on July 21, 2021. 
 
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. 
The Plan says the item 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 item. Our physician reviewer found the 
review has determined that the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for the form fitting conductive garment for delivery of TENS or NMES (CPT code E0731) provided on 
July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extractions (D7140 x 2) provided on 
November 4, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that the Evidence of Coverage states that 
"you are not required to use an in network provider for your non-Medicare covered dental services. Every year, 
the plan reimburses up to $1,250 for non-Medicare covered preventive and comprehensive dental services 
combined." The Plan denied your request. The Plan says payment cannot be made to a provider that has opted 
out of Medicare. 
 
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, dental services received from a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the extractions (D7140 x 2) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on July 13, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that the dentist office told you that they 
accepted your insurance. You also say that you were never made aware that the treating provider is OON. The 
Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that 
this claim was processed at the OON level with a $0 copayment, and you can be billed the difference between 
what was billed and what was paid. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount because the service was received OON. Therefore, we decided 
that the Plan does not have to pay for the resin-based composite (D2393) provided on July 13, 2021 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 resin-based composite (D2393), and intraoral imaging 
(D0220 and D0230) provided by a participating provider on November 12, 2021. 
 
You asked the Plan to pay for a resin-based composite and intraoral imaging. You say that you would like this 
claim paid. You say that this dentist was not good. The Plan denied your request. The Plan says the benefit 
limit for these 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. The Plan covers one resin-
based composite every two years and one intraoral imaging every year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2393, D0220, and D0220 was 
previously provided on May 4, 2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite and intraoral imaging have already been met. Therefore, we decided that the Plan 
does not have to pay for a resin-based composite (D2393), and intraoral imaging (D0220 and D0230) provided 
by a participating provider on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 64447-59 RT) provided on May 7, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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. 
 
CPT code 64447-59 RT (1 Unit) remains not supported. This code is included in CPT code 01402; therefore, it 
cannot be separately reimbursed. The documentation received did not support that the procedure or service was 
distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. 
The submitted documentation does not support that the service was performed at the request of the surgeon for 
post-operative pain management. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia (CPT 
code 64447-59 RT) provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to a crown (D2954) for tooth # 
7, partial lower denture (D5214), and partial upper denture (D5213). 
 
You asked the Plan to pre-approve the post and core in addition to a crown. You say that the dental provider 
made the dentures wrong. You say that it is affecting your health. You also say that you returned the dentures 
to the provider and cancelled with them. The Plan denied your request. The Plan says post and core in addition 
to a crown is not listed as a covered service. 
 
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 post and core in addition 
to a crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve post and core in addition to a crown (D2954) for tooth # 7, partial lower denture (D5214), and 
partial upper denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan of the 
abdomen and pelvis provided on August 5, 2021, and a magnetic resonance imaging (MRI) of the pelvis 
provided on September 30, 2021. 
You asked the Plan to waive the copayments for a CT scan and an MRI of the pelvis. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $80 
copayment for radiological diagnostic services, including CT scans and MRIs.  
 
You have been asked to pay a total of $160, which a $80 copayment for each a CT scan and an MRI ($80 
copayment + $80 copayment = $160). A CT scan and an MRI fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the 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 waive the copayments for a 
computed tomography (CT) scan of the abdomen and pelvis provided on August 5, 2021, and a magnetic 
resonance imaging (MRI) of the pelvis provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided December 9, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you don't feel the pre-surgical evaluation 
should have been billed as an emergency exam. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited 
oral exam once per year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on November 8, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for 
tooth #2. 
 
You asked the Plan to pre-approve a crown. You say that a crown is necessary to prevent this tooth from 
splitting apart and creating more problems. The Plan denied your request. The Plan says this tooth does not 
have significant breakdown due to decay or trauma, and therefore this service is 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 Plan's coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
requested crown is not medically necessary. Our physician reviewer found that the clinical notes indicate that 
there are no caries present, but the tooth shows heavy wear, and the provider suggested a crown for the tooth. 
The radiograph shows some occlusal wear but no carious lesions and fully intact cusps. The Plan provides that 
for consideration for a crown there must be four or more involved surfaces and two or more cusps. In this 
instance, there is no carious lesion present, no previously restored or damaged surfaces other than an occlusal restoration and no cuspal involvement. Given the lack of structural damage to tooth #2, there can be no necessity found for a crown restoration on this tooth. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided February 12, 2021. 
 
You asked the Plan to pay for the molar endontics. You say that you were told if your physician ordered the 
dental services, they would be covered. The Plan denied your request. The Plan says you have used your full 
dental allowance and therefore no further payment for dental services is due. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers certain 
supplemental dental services up to a $400 benefit every calendar year. 
 
We looked at the file and Medicare rules.  The Plan has provided your full dental benefit of $400 for services you received on January 14, 2021, and June 1, 2021. Thus, you do not have any remaining dental benefit to apply towards the requested services provided February 12, 2021. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) provided February 12, 2021.  
 
Your complaint about potentially being provided misinformation about benefits from a Plan representative 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 27, 2021, to August 31, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not medically necessary.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from August 27, 2021 to August 31, 2021. The records did not document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care. Daily skilled services were not required (or provided) from August 27, 2021 to August 31, 2021. For the five days in question in this case, the enrollee was seen for two sessions with physical therapy and three sessions each with occupational and speech therapies. The enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case with part time therapy services provided from August 27, 2021 to August 31, 2021. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 27, 2021, to August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided August 27, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that your provider gave you a lower estimate for 
your services than what you were billed after they were rendered. The Plan denied your request. The Plan says 
they have agreed to pay for your dental extractions according to your benefits, however the limited oral exam 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 
limited oral evaluation - problem focused (D0140) provided August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 surgical extractions (D7210), 4 alveoloplasty in 
conjunction with extractions (D7310), and removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says surgical extractions, alveoloplasty, and removal of torus mandibularis are not listed 
as covered services. 
 
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 surgical extractions, 
alveoloplasty, and removal of torus mandibularis are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve 17 surgical extractions (D7210), 4 alveoloplasty in 
conjunction with extractions (D7310), and removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - two surfaces, anterior (D2331) 
and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided November 2, 2021. 
 
You asked the Plan to pay for the two additional fillings and additional tooth extraction. You say that the 
services were necessary, and you were unaware that you had a frequency limit. The Plan denied your request. 
The Plan says you have exceeded the frequency limit for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two 
composite fillings and two tooth extractions per year. 
 
We looked at the file and Medicare rules. The Plan provided documentation that two fillings and two tooth extractions were covered on the same date of service. Based on this information, we decided that the Plan's 
frequency limits for coverage of the composite fillings and tooth extraction have been exceeded. Therefore, we 
decided that the Plan does not have to pay for the two additional resin-based composites - two surfaces, anterior 
(D2331) and the additional extraction, erupted tooth or exposed root (elevation and/or forceps removal) 
(D7140) provided November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical services to be provided as part of a clinical trial. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee must access services from participating providers. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve surgical services to be provided as part of a clinical trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic 
crown (D6058). 
 
You asked the Plan to pre-approve an endosteal implant, custom fabricated abutment and abutment supported 
crown. You say that you would like the implant services covered. The Plan denied your request. The Plan says 
these services are 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 pre-approve surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 22 endosteal implants (D6010). 
 
You asked the Plan to pre-approve 22 implants. You say that this is an emergency. You say that you cannot 
even eat. The Plan denied your request. The Plan says dental implants 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 22 dental implants are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
22 endosteal implants (D6010).