Persius/hicric huggingface dataset:
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 January 26, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you would like this service to be covered. 
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 Plans coverage rules apply in this case. The Plan covers the limited 
oral exam once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited exam was 
previously covered on January 26, 2022. 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 January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0120, D0274, D4910) provided March 11, 
2021 to December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the provider has opted out of Medicare and is 
not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services (D0120, D0274, D4910) provided March 11, 2021 to December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4267), and oral hygiene 
instructions (D1330), provided by a participating provider on March 16, 2022. 
 
You asked the Plan to pay for a guided tissue regeneration and oral hygiene instructions. You say that these 
services were medically necessary. The Plan denied your request. The Plan says the denied services are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a guided 
tissue regeneration (D4267), and oral hygiene instructions (D1330), provided by a participating provider on 
March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on January 19, 2022. 
 
You asked the Plan to pay for the diagnostic casts. You say that two teeth were cracked and black, and they 
needed to be removed according to your dentist. The Plan denied your request. The Plan says this service is not 
a covered benefit 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 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 
diagnostic casts (D0470) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
November 17, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the dentist determined the x-rays were 
medically necessary. 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 Plans coverage rules apply in this case. The Plan covers the bitewings 
once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were 
previously covered April 27, 2021. Based on this information, we decided that the Plan's frequency limit for 
coverage of the bitewings has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
bitewings - four radiographic images (D0274) provided November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests and a dental consultation (D9310, D0460) 
provided September 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these procedures are not covered under your 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 pulp 
vitality tests and a dental consultation (D9310, D0460) provided September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on December 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your 
request. The Plan says consultation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
February 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that the office staff confirmed the cleaning would be 
covered. You say that the office staff refused to change the code billed even though they had knowledge of 
your previous visit. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered 
every 3 plan years. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on August 10, 2021. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81238, 81220, 81226, 81335, 
81230, 81227, 81355, 81241, 81291 and 81240) provided on July 13, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. 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. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291 and 81240) provided on 
July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the panoramic x-ray (D0330) 
and 3 extractions (D7140) provided on January 28, 2021, by the out of network dentist. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you understand that 
the dentist is out of network. You say that this dentist charges less than in network dentists. You also say that 
you feel you should be reimbursed the standard in network amount. The Plan denied your request. The Plan 
says that out of network dentists may bill you for any amount greater than what the Plan pays. 
 
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 and the services are listed as covered, 
you may pay more for dental services received out of network. Cost sharing is a contractual obligation under 
the plan and cannot be waived. Therefore, we decided that the Plan does not have to reimburse an additional 
amount for the panoramic x-ray (D0330) and 3 extractions (D7140) provided on January 28, 2021, by the out 
of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioventus DBM Allograft (20930). 
 
You asked the Plan to pre-approve Bioventus DBM Allograft (20930). You say that the requested Bioventus 
DBM Allograft (20930) is medically necessary. The Plan denied your request. The Plan says the requested 
Bioventus DBM Allograft (20930) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve Bioventus DBM Allograft (20930). Our 
reviewer says that the requested Bioventus DBM Allograft (20930) is not medically necessary. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Bioventus DBM allograft (20930) in the setting of lumbar fusion, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bioventus DBM Allograft (20930) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Bioventus DBM Allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided February 15, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this item is not covered 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 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 an 
occlusal guard (D9944) provided February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the extraction (D7140), 
and the first periapical x-ray (D0220) provided by an out-of-network provider form January 27, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), the extraction (D7140), and the first 
periapical x-ray (D0220). You say that you were told the facility accepted the dental plan which is why you 
went to that facility. You say the Plan should pay for these services because you would never go out-of-
network. The Plan denied your request. The Plan says you pay 100% for out-of-network 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 limited oral evaluation (D0140), 
the extraction (D7140), and the first periapical x-ray (D0220) are not among those covered under this benefit 
when rendered by an out-of-network provider. The record shows the provider was out-of-network. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the extraction (D7140), 
and the first periapical x-ray (D0220) provided by an out-of-network provider form January 27, 2022, to 
January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 
provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 codes 81206, 81292, and 81301 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that one code was billed for the panel. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 provided on 
October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and periodic oral 
evaluations - established patient (D0120) provided February 3, 2021, to November 11, 2021. 
 
You asked the Plan to pay for the periodontal maintenance and periodic oral exam. You say that 4 cleanings 
per year were recommended, and you feel they should be covered. The Plan denied your request. The Plan says 
the claims 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. The Plan covers the periodic 
oral exam and periodontal maintenance once in a calendar year. This benefit includes a $50 office visit 
copayment. The periodontal maintenance has 50% coinsurance after the $50 deductible is met. 
 
We looked at the file and Medicare rules. You have been asked to pay $134 for the periodontal maintenance 
provided November 11, 2021. This amount included your $50 deductible as well as $42 applied to the office 
visit copayment. The remaining periodontal maintenance have exceeded the Plan's frequency limit. 
Additionally, the Plan provided documentation showing that a periodic oral exam was covered on June 7, 2021. 
You were asked to pay a $50 copayment for this service. The periodic oral exam provided February 3, 2021, 
has exceeded the Plan's frequency limit.  Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) and periodic oral evaluations - established patient (D0120) provided 
February 3, 2021, to November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) and 
core buildup, including any pins when required (D2950) provided January 18, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were not aware that your benefits 
changed drastically in 2022. 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 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 crown 
- porcelain fused to high noble metal (D2750) and core buildup, including any pins when required (D2950) 
provided January 18, 2022.  
 Your complaint about potentially not being adequately informed about changes to 2022 dental benefits 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350), oral hygiene instructions (D1330), 
and gingival irrigation (D4921), provided by a participating provider on December 22, 2021. 
 
You asked the Plan to pay for 2D oral imaging, oral hygiene instructions, and gingival irrigation. You say that 
you feel like the Plan should pay for this. The Plan denied your request. The Plan says this claim has been 
processed 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 2D oral imaging (D0350), oral hygiene instructions (D1330), and gingival irrigation (D4921), provided by a 
participating provider on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service was medically necessary. 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 root canal not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) provided 
on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), the dental cleaning (D1110), 
and the complete intraoral x-rays (D0210) provided by an out-of-network provider on February 22, 2022. 
 
You asked the Plan to pay for the periodic oral exam (D0120), the dental cleaning (D1110), and the complete 
intraoral x-rays (D0210). You say that you were given the wrong information and that the dentist was in-
network. The Plan denied your request. The Plan says you pay 100% for out-of-network 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodic oral exam (D0120), the 
dental cleaning (D1110), and the complete intraoral x-rays (D0210) are not among those covered under this 
benefit when rendered by an out-of-network provider. The record shows the provider is out-of-network. 
Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120), the dental 
cleaning (D1110), and the complete intraoral x-rays (D0210) provided by an out-of-network provider on 
February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940), and periapical x-ray 
(D0220) provided on March 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were given the name of this provider by a 
plan representative. You also say that your plan makes everything so difficult. The Plan denied your request. 
The Plan says no additional payment will be made for this claim. 
 
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 protective restoration is not among 
those covered under this benefit. Additionally, the frequency limit of 1 periapical x-ray per calendar year has 
been exceeded. The record shows that the Plan paid for a periapical x-ray you received on February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the protective restoration (D2940), and periapical 
x-ray (D0220) provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81301 and 81311) provided 
on August 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing 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. 
 
We looked at the file and Medicare rules. We find that the various denied CPT codes are not supported in the 
medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81206, 81301 and 81311) 
provided on August 23, 2021.