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

 
We decided that the Plan does not have to pay for the lower partial denture (D5214) provided by a network 
provider on February 17, 2022. 
 
You asked the Plan to pay for the lower partial denture (D5214). You say that you need the partial denture due 
to cancer. 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, the lower partial denture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the lower partial 
denture (D5214) provided by a network provider on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 83970, and 84100) provided 
on January 6, 2022. 
 
You asked the Plan to pay for codes 82310, 83970, and 84100. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 83970, and 84100) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by 
participating provider on February 7, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that this exam was necessary for the 
dental work you were having done. The Plan denied your request. The Plan says the benefit limit for D0150 has 
already been met and 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 a 
comprehensive oral evaluation once every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on March 6, 2019. Based on this information, we decided that the Plan's rules for coverage of a comprehensive 
oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by a participating provider on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 9, 2022, to February 16, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you did not know you could only 
have one exam every three years. The Plan denied your request. The Plan says the benefit limit for D0150 has 
already been met and 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 a 
comprehensive oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The benefit limit for a comprehensive oral evaluation has already 
been met. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral 
evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided on February 9, 2022, to February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (code D7250) you 
received on February 4, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that you were not aware of these 
charges prior to getting this service performed.  You said that your dentist never told you that this extraction 
would be an additional cost.  You said that you cannot afford this bill. The Plan denied your request. The Plan 
says this service is not covered under your dental benefits.  The Plan says that you only have basic dental 
coverage because you did not sign up for the optional supplemental dental benefit until March 1, 2022. 
 
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. Records show that on the date 
of service in question, you had only signed up for the Plan's basic dental benefit.  Under this benefit, only those 
dental services explicitly listed on pages 4-81 through 4-84 of your Evidence of Coverage are covered.  Code 
D7250 is not listed under this benefit.  While this code is covered under the optional benefit you did not sign up for this extra benefit until March 1, 2022. 
 
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 
removal of residual tooth roots (code D7250) you received on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367), intraoral - periapical each 
additional radiographic image (D0230), and 2D oral/facial photographic image obtained intra-orally or extra-
orally (D0350) provided February 24, 2022. 
 
You asked the Plan to pay for the cone beam CT scan, additional periapical x-rays, and 2D photographic 
images. You say that you don't recognize this business. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for the periapical x-ray, and the cone beam CT scan and 2D photographic images 
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. The Plan covers one periapical x-ray per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that one periapical x-ray 
was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit 
for coverage of periapical x-rays has been exceeded. Though the Plan offers dental benefits in excess of 
Medicare coverage, the cone beam CT scan and 2D photographic images are not among those covered services. 
Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws; with or without cranium (D0367), intraoral - 
periapical each additional radiographic image (D0230), and 2D oral/facial photographic image obtained intra-
orally or extra-orally (D0350) provided February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on February 1, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were under the impression that 
the intraoral x-rays were the normal x-rays that are done each year when you have your teeth cleaned. The Plan 
denied your request. The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and 
additional intraoral periapical x-ray (D0230) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extraction 
(D7210) provided on March 23, 2022. 
 
You asked the Plan to reimburse you for the dental services. You say that you went to this office because there 
is no other office that accepts your plan in the area. You also say that you would like to be reimbursed for these 
services. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral evaluation and extraction are 
not among those covered under this benefit when performed by an out of network dentist.  

Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and 
extraction (D7210) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implant (D6010), the cone beam computed 
tomography (CT) image of one full dental arch (D0381), and deep sedation (D9222) provided by a network 
provider from March 9, 2021, to July 13, 2021. 
 
You asked the Plan to pay for the endosteal implant (D0610), the cone beam CT image of one full dental arch 
(D0381), and the deep sedation. You say that you were told that the Plan would cover up to $5,000 for dental 
implants. The Plan denied your request. The Plan says the 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 endosteal implant (D6010), the 
cone beam computed tomography (CT) image of one full dental arch (D0381), and deep sedation (D9222) are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
endosteal implant (D6010), the cone beam computed tomography (CT) image of one full dental arch (D0381), 
and deep sedation (D9222) provided by a network provider from March 9, 2021, to July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D0657) and the abutment 
supported porcelain/ceramic crown (D0658) provided by a network provider on February 23, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment (D0657) and the abutment supported 
porcelain/ceramic crown (D0658). You say that this was a necessary procedure and was not just cosmetic. You 
say your dental benefits should cover this using your dental allowance with the 50% coinsurance. The Plan 
denied your request. The Plan says the 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 custom fabricated abutment 
(D0657) and the abutment supported porcelain/ceramic crown (D0658) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D0657) 
and the abutment supported porcelain/ceramic crown (D0658) provided by a network provider on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen testing by nucleic acid provided on November 
22, 2021, billed with code 87471. 
 
You asked the Plan to pay for the billed lab testing. You say that this testing should be considered medically 
necessary and paid. The Plan denied your request. The Plan says all testing was approved except for code 
87471. This code is not supported by the records. 
 
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 87471 is Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique. 
 
We find that CPT code 87471 is not supported in the medical record. Specifically, the test results do not show 
that testing for Bartonella henselae and Quintana was performed. Based on this information, we decided that 
Medicare rules for coverage of the billed lab testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathogen testing by nucleic acid provided on November 22, 2021, billed with code 
87471.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on October 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, 
any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, there is no 
documentation of an adjacent tissue transfer or rearrangement of any area for 30.1 to 60 sq cm to support code 
14031. There is no documentation of an adjacent tissue transfer or rearrangement of any area for each 
additional 30 sq cm to support code 14302. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 19380 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on September 27, 2021. 
 
You asked the Plan to pay for the dental items. You say that you were approved for dentures on April 12, 2021. 
You say that unbeknownst to you your plan changed on September 1, 2021. You also say that you should be 
reimbursed for this work. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 complete dentures are not among 
those covered under this benefit. The record shows that the predetermination of benefits advises it is not a 
guarantee of payment. Additionally, the record shows that a letter was sent to you notifying you of the plan 
change on July 7, 2021, and a phone call was made on July 8, 2021. 
  Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and 
complete lower denture (D5120) provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided by an out-of-network provider on January 10, 2022, to January 11, 2022. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation. 
You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rules for 
D4346 have not been met. 
 
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 scaling in 
presence of generalized moderate or severe gingival inflammation for ages 0-20. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of scaling in presence of generalized moderate or severe gingival inflammation have not been met.  
 
 Therefore, we decided that the Plan does not have to pay for scaling in presence of generalized moderate or 
severe gingival inflammation (D4346) provided by a participating provider on January 10, 2022, to January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular disease screening tests (CPT code 81479) 
provided on July 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation does not indicate how the test results will assist in managing the member's condition. 
Therefore, the denial of the cardiovascular screening/risk assessment panel is administratively upheld for not 
meeting Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for 
cardiovascular disease screening tests (CPT code 81479) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental cone beam imaging (code D0364). 
 
You asked the Plan to pre-approve cone beam. You say that if you don't get this service done then you will 
need to have your teeth extracted. The Plan denied your request. The Plan says this service is 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. 
 
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 
dental cone beam imaging (code D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4) and 
the lower partial denture (D5214) to be provided by a network provider. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing (D4341 x 4) and the lower partial 
denture (D5214). You say that your dentist says you need these services and was unaware they would not be 
covered. The Plan denied your request. The Plan says the services are 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 periodontal scaling and root 
planing (D4341 x 4) and the lower partial denture (D5214) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 
x 4) and the lower partial denture (D5214) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210), anesthesia (D9222, 
D223), and therapeutic parenteral drugs (D9612) to be performed by an opt-out provider. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has had bad experiences which 
have caused post traumatic stress disorder (PTSD) with dental providers. You say that the enrollee cannot have 
procedures done without anesthesia. You say that the only in network provider available is the one to have 
caused your PTSD. You also say that you would like an exception to be made for this to be covered as an out 
of network claim. The Plan denied your request. The Plan says payment cannot be made to a provider that has 
opted out of Medicare or is out of network. 
 
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 when performed by a provider that has opted out of Medicare or is out 
of network. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), 
anesthesia (D9222, D223), and therapeutic parenteral drugs (D9612) to be performed by an opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard, soft appliance (D9945). 
 
You asked the Plan to pre-approve the dental item. You say that you need a night guard. You say that you 
clench and grid your teeth. You say that your dentist advised you needed to use the soft one. You also say that 
you would like this to be covered. The Plan denied your request. The Plan says occlusal guard, soft appliance, 
is not listed as a covered dental item. 
 
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 occlusal guard, soft 
appliance, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an occlusal guard, soft appliance (D9945).