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

 
We decided that the Plan has to pay for endosteal implants on tooth #20 and 29 provided on November 4, 2021. 
 
You asked the Plan to pay for endosteal implants. You say that you did not know the dentist did not accept 
Medicare. The Plan denied your request. The Plan says that this provider has opted out of Medicare and is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide enough information allowing us to confirm the 
providers national provider identifier (NPI). 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. 
  
We are unable to confirm if the provider you received services from has opted out of Medicare, as the address 
location provided in the record is different than the one listed on the Medicare opt out website. We were also 
unable to confirm the providers NPI based on the information provided by the Plan. Therefore, we decided 
that the Plan has to pay for endosteal implants on tooth #20 and 29 provided on November 4, 2021.  
 
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 a crown on tooth #12 (D2740) and core build up on tooth 
#12 (D2950) provided on March 23, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that you disagree with the denial for the 
dental services. The Plan denied your request. The Plan says a crown (D2740) and core build up (D2950) are 
not covered by your supplemental 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 a crown 
on tooth #12 (D2740) and core build up on tooth #12 (D2950) provided on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy (44180) provided on December 7, 2020. 
 
You asked the Plan to pay for the laparoscopy (44180). You say that you did not consent for provider claims to 
be processed as PPO network. You say that you are willing to negotiate a 10% discount for the medically 
necessary services and payment of $56,021.18 should be sent. The Plan denied your request. The Plan says 
procedure code 43289 has been overturned and procedure code 44180 cannot be billed with a modifier to 
bypass the code pair. 
 
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 44180 
is a column II code to column I code 43860 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 laparoscopy (44180) provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewing x-rays (D0277) provided on February 2, 2022. 
 
You asked the Plan to pay for x-rays. You say that you disagree with the denial of the dental services. The Plan 
denied your request. The Plan says vertical bitewing x-rays (D0277) 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 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 vertical 
bitewing x-rays (D0277) provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by a chiropractor from January 7, 
2022, to February 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the plan should pay for the active treatment 
to correct acute injuries. The Plan denied your request. The Plan says Medicare does not cover physiotherapy 
rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that you received manual therapy (97140), diathermy (97024), and therapeutic exercises 
(97110), These services, when provided by a chiropractor are not a covered benefit. Therefore, we decided that 
the Plan does not have to pay for the services provided by a chiropractor from January 7, 2022, to February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rebase complete maxillary denture on January 5, 2022. 
 
You asked the Plan to pay for a rebase complete maxillary denture. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says services for codes, D5710 and 
D5711, were correctly denied as they are not 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a rebase 
complete maxillary denture on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6245, D6740, D2950). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the bridge would be replacing a missing posterior tooth, and would not be 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. The Plan covers the services 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that a request for a 
three unit bridge from tooth #3-5, replacing tooth #4, has been made. The abutment teeth appear to be stable 
and able to act as supports for a replacement tooth. The plan provisions excludes bridgework in most cases 
except where there is a single missing anterior tooth. In this instance there is a single missing posterior tooth, 
#4. The bridge requested would necessarily involve a posterior tooth, a condition not covered under the plan 
provisions. Although the requested treatment is reasonable, the plan limitations does not allow for posterior bridges and the Plan criteria has not been met. 
 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D6245, D6740, D2950).
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-ray 
(D0210) provided on December 9, 2021. We also decided the Plan does not have to waive the cost share for 
periodontal scaling and root planing (D4341 x 4) provided on December 9, 2021. You asked the Plan to 
pay for an evaluation, x-ray, and periodontal scaling. You say that the office staff 
indicated that the insurance would cover 100% of the dental charges. The Plan denied your request. The Plan 
says a comprehensive oral evaluation and intraoral x-ray are covered services by the Plan's dental benefits; 
however, your benefit for one evaluation (D0150) every three years and one intraoral x-ray (D0210) every five 
years has been exhausted. The Plan also says that you have been charged the correct cost sharing for 
periodontal scaling and root planing. 
 
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 one 
evaluation (D0150) every three years and one intraoral x-ray (D0210) every five years. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation and intraoral x-rays provided on April 16, 2019; therefore, the benefit for a 
comprehensive oral evaluation and intraoral x-rays has been exhausted. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) provided on 
December 9, 2021.  
 
You have been asked to pay $95.20, which is 70% coinsurance of the allowed amount for periodontal scaling 
and root planning for each quadrant ($136 allowed amount x 70% coinsurance = $95.20). Periodontal scaling 
and root planning falls within the Dental Services 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 also decided the Plan does not have to waive the 
cost share for periodontal scaling and root planing (D4341 x 4) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350), intraoral x-rays 
(D0210), and a comprehensive oral evaluation (D0150) provided on March 2, 2022. 
 
You asked the Plan to pay for imaging, x-rays, and an evaluation. You say that you had to have new x-ray to 
establish as a new patient with this provider. The Plan denied your request. The Plan says 2D oral/facial 
photographic images (D0350) are not covered by your dental benefits. Intraoral x-rays (D0210) and a 
comprehensive oral evaluation (D0150) are covered services once every three Plan years by the Plan's dental 
benefits; however, your benefits for both services have 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. The Plan covers intraoral x-
rays (D0210) and a comprehensive oral evaluation (D0150) once every three Plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D oral/facial photographic images 
(D0350) requested are not covered under this benefit. We looked at this case file, the Plan's rules, and Medicare 
rules. The record shows the Plan paid for intraoral x-rays and a comprehensive oral evaluation 
provided on December 15, 2020; therefore, the benefit for intraoral x-rays and a comprehensive oral evaluation 
has been exhausted. Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic 
images (D0350), intraoral x-rays (D0210), and a comprehensive oral evaluation (D0150) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation per quadrant (D4921) to be provided 
by a network provider. 
 
You asked the Plan to pre-approve the gingival irrigation per quadrant (D4921). You say that you are appealing 
the denial. The Plan denied your request. The Plan says the 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, gingival irrigation per quadrant 
(D4921) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve gingival irrigation per quadrant (D4921) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services (D1110, D0274, D0120) provided 
on April 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as you saw 
an out-of-network provider and out-of-network providers can bill you for additional costs if what they charge is 
more than the maximum payable benefit amount for preventive services 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 services were provided out-of-
network. Therefore, we decided that the Plan does not have to pay more for the dental services (D1110, D0274, 
D0120) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (dental code D0431), oral 
hygiene instructions (dental code D1330), and periodontal procedure (dental code D4999) for tooth #1 
provided on February 8, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, oral hygiene instructions, and periodontal 
procedure. You say that you would like for the Plan to pay for these services. The Plan denied your request. 
The Plan says The Plan says the denial of payment for these services is correct, because these services are not 
covered by the Plan's 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. The Plan does not cover 
adjunctive pre-diagnostic test, oral hygiene instructions, or periodontal procedures. 
 
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 
adjunctive pre-diagnostic test (dental code D0431), oral hygiene instructions (dental code D1330), and 
periodontal procedure (dental code D4999) for tooth #1 provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on November 10, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 83789 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of complete description of the not elsewhere classified code and this code is not 
separately reimbursed when billed for specimen validity testing on specimens used for drug testing. In addition, 
this code is not separately reimbursed when billed for specimen validity testing on specimens used for drug 
testing. This means the billed code and modifier cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the mass spectrometry and tandem mass spectrometry services have not been 
met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry services coded 83789 provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and cone beam imaging (D0364) 
provided on February 14, 2022. 
 
You asked the Plan to pay for a consultation and imaging. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a consultation (D9310) and cone beam imaging (D0364) 
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 a 
consultation (D9310) and cone beam imaging (D0364) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of tooth roots on tooth #27 (D7250) and intra-
socket biological dressing placement on tooth # 19, 21, and 27 (D7922). 
 
You asked the Plan to pay for removal of tooth root and dressing placement. You say that you had no choice 
but to go to an out-of-network provider due to COVID-19. The Plan denied your request. The Plan says two 
oral surgery procedures (D7250) are covered per calendar year which has been exhausted. The Plan also says 
that intra-socket biological dressing placement (D7922) is 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 Plan's coverage rules apply in this case. The Plan covers two oral 
surgery procedures per calendar year.  We looked at this case file, the Plan's rules, and Medicare rules. 
The record shows the Plan paid for two tooth root removals provided on the same date of service; therefore, 
the benefit for oral surgery procedures has been exhausted. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the intra-socket biological dressing placement is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the removal of tooth roots on tooth #27 (D7250) 
and intra-socket biological dressing placement on tooth # 19, 21, and 27 (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #19 (D7210) provided on January 28, 2022. 
 
You asked the Plan to pay for an extraction. You say that you received notices from the insurance company 
saying that you did not owe anything. The Plan denied your request. The Plan says an extraction (D7210) is 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 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 an 
extraction of tooth #19 (D7210) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial dentures (D5214) provided on February 
16, 2022. 
 
You asked the Plan to pay for partial dentures. You say that you disagree with the denial of the partial dentures. 
The Plan denied your request. The Plan says mandibular partial dentures (D5214) 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 
mandibular partial dentures (D5214) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the lower left quadrant. 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by the Plan's 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 pre-approve 
gingival irrigation (D4921) for the lower left quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on December 13, 2021. 
 
You asked the Plan to pay for limited oral evaluation (D0140). You say that you needed the service provided. 
The Plan denied your request. The Plan says services exceeds the plan frequency limitations for this procedure. 
 
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. Limited oral evaluation 
(D0140) is allowed one time per plan year. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received covered limited oral 
evaluation (D0140) on July 26, 2021. Therefore, this benefit was exhausted as of December 13, 2021. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on 
December 13, 2021.