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

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), radiographic/surgical 
implant index (D6190), surgical placement of implant body: endosteal implant (D6010), and custom fabricated 
abutment (D6057). 
 
You asked the Plan to pre-approve a bone replacement graft, radiographic/surgical implant index, endosteal 
implant, and custom fabricated abutment. You say that you would like to appeal these services. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263), radiographic/surgical implant index (D6190), surgical placement of implant 
body: endosteal implant (D6010), and custom fabricated abutment (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0380) provided on February 10, 2022. 
 
You asked the Plan to pay for imaging. You say that this special type of imaging was medically necessary. The 
Plan denied your request. The Plan says cone beam imaging (D0380) is not covered by the Plan's routine 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 cone 
beam imaging (D0380) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x 2), unspecified periodontal 
procedure (D4999 x 2), and oral hygiene instructions (D1330) provided on March 11, 2022. 
 
You asked the Plan to pay for gingival irrigation, periodontal procedures, and instructions.. You say that you 
disagree with the denial for dental services. The Plan denied your request. The Plan says gingival irrigation 
(D4921), unspecified periodontal procedure (D4999), and oral hygiene instructions (D1330) 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 gingival 
irrigation (D4921 x 2), unspecified periodontal procedure (D4999 x 2), and oral hygiene instructions (D1330) 
provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant placements (D6010) for teeth #22 and 
#27. 
 
You asked the Plan to pre-approve dental implants. You say that you should have the option to have these 
services covered. The Plan denied your request. The Plan says implants are not covered by 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 pre-approve 
dental implant placements (D6010) for teeth #22 and #27.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Otezla 30mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
enrollee's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Otezla 30mg tablet 
medication.  
 Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on December 7, 2021. 
 
You asked the Plan to pay for an evaluation, x-rays, and prophylaxis. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says these services are not covered when received 
by an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 when received by an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays (D0230), 
bitewing x-rays (D0274), and prophylaxis (D1110) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 10, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says the drug testing was approved for payment; 
however, code 83789 is for validity testing that is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 10, 2021, billed with code 83789.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound study of the veins of one 
arm or leg (93971) provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this service was medically 
necessary, and you do not understand why the Plan had not paid for any part of the cost of this ultrasound. The 
Plan denied your request. The Plan says this service is covered, and your copayment has been assessed in 
accordance with your contract. 
 
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 $120 
copayment for Medicare-covered radiological diagnostic services other than x-rays.  
 
 You have been asked to pay a $94.61 copayment for the ultrasound. An ultrasound falls within the Medicare-
covered radiological diagnostic services benefit category. The record shows that the provider billed the Plan a 
total of $253 for this service. Because the ultrasound is medically necessary and is covered, the Plans 
discounted rate applies. The Plans allowed amount (discounted rate) for this service in this case is $94.61. You 
are being asked to pay the full allowed amount because it is less than your required copayment for this service. 
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 copayment for the ultrasound study of the veins of one arm or leg (93971) 
provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 2), and 2D 
photographic image (D0350) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how the frequency 
limitation has been reached. You say that you have not been to see a dentist in a long time. You also say that 
you needed x-rays to determine the necessary treatment. The Plan denied your request. The Plan says 1 
periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The 
Plan also says that 2D photographic image 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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for the initial 
periapical x-ray that you received on the date of service in this case. Additionally, the 2D photographic image 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional periapical x-rays (D0230 x 2), and 2D photographic image (D0350) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation and intraoral x-ray (D0150, D0210) 
provided on November 20, 2021. 
 
You asked the Plan to pay for the oral evaluation and intraoral x-ray. 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 they do not fall within your plan benefits, and you do not have any additional dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an oral evaluation and intraoral 
x-ray (D0150, D0210) provided on November 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites of one surface (D2391 x2) 
and resin-based composite of two surfaces (D2392) provided on March 8, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that the receptionist advised you that these 
services would be covered. You also say that it is difficult for you to come up with the money to pay for these 
services. The Plan denied your request. The Plan says these services are not covered benefits under your dental 
plan. The Plan also says that the Plan offers a plan which does offer additional coverage for dental 
services, but you were not enrolled on this date of 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
resin-based composites of one surface (D2391 x2) and resin-based composite of two surfaces (D2392) 
provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) without documented bronchiectasis. The records do not document the presence of one of the enumerated conditions for which coverage is allowed. The services are therefore not reasonable or 
medically 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for lab services. You say that the enrollee did not come to the lab so he is not using 
out-of-network benefits. The Plan denied your request. The Plan says services were not referred by a network 
provider and these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory (lab) services provided on February 24, 
2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
December 22, 2021. 
 
You asked the Plan to pay for a crown. You say that this crown was medically necessary. The Plan denied your 
request. The Plan says services provided by an out-of-network provider 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 Plans coverage rules apply in this case. The Plan covers a crown when 
the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided by an out-of-network provider on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided February 23, 2022. 
 
You asked the Plan to pay for the periapical x-ray. You say that you feel you overpaid for the services. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for this service. The Plan also 
says they have reached out to the dental office about over payment and you can contact the office if you still 
need to resolve the issue. 
 
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 periapical 
x-ray once every three years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a periapical x-ray 
was previously covered on August 21, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the periapical x-ray has been exceeded. Therefore, we decided that the Plan does not have 
to pay for the intraoral - periapical first radiographic image (D0220) provided February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473 x 2). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need to get this 
procedure done before getting dentures. The Plan denied your request. The Plan says the removal of torus 
mandibularis (D7473) is not covered by your routine 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 the 
removal of torus mandibularis (D7473 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on October 30, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported 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. In this case, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not note that 
30-74 minutes were spent with this enrollee on the date in question. Based on this information, we decided that 
Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care, first hour (99291) provided on October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), 
prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120) provided March 9, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the fluoride varnish, dental cleaning and periodic oral exam. You say that you 
were not aware of the provider's status prior to the services being rendered. The Plan denied your request. The 
Plan says these services are not covered when provided OON. 
 
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 fluoride 
varnish, dental cleaning and periodic oral exam when the services are provided by a network provider. 
 
We looked at the file and Medicare rules. The services in this case were provided OON. Based on this information, 
we decided that the Plan's rules for coverage of the fluoride varnish, dental cleaning and periodic 
oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206), prophylaxis - adult (D1110), periodic oral evaluation - established 
patient (D0120) provided March 9, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (99336) provided on January 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the assisted living facility is responsible 
to obtain prior authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health services (99336) provided on 
January 27, 2022, by an out-of-network (OON) provider.