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

 
We decided that the Plan does not have to pre-approve five precision attachments (D5862 x5). 
 
You asked the Plan to pre-approve the precision attachments. You say that you would like the attachments to 
be approved for the enrollee because the implants were approved and paid for. The Plan denied your request. 
The Plan says this service is not covered under the enrollee's benefit 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 pre-approve five 
precision attachments (D5862 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services provided on December 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code accurately represents the exam 
performed. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
We looked at the file and the rules. The records show that the enrollee received a medical eye exam for 
cataracts and diabetes. The eye refraction is only covered when performed as part of a routine eye exam. 
Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341), gingival irrigation - per quadrant (D4921), topical application of fluoride varnish 
(D1206), and oral hygiene instructions (D1330) provided December 28, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing, gingival irrigation, fluoride varnish and 
oral hygiene instructions. You say that you would like these services covered. The Plan denied your request. 
The Plan says these services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), gingival irrigation - per 
quadrant (D4921), topical application of fluoride varnish (D1206), and oral hygiene instructions (D1330) 
provided December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite (D2330), posterior resin-
based composite (D2392), two periodontal scalings and root planings (D4341 x2), and two gingival irrigations 
(D4921 x2) provided on December 23, 2021. 
 
You asked the Plan to pay for the resin-based composites, scalings and planings, and gingival irrigations. The 
Plan denied your request. The Plan says these services are not covered under your benefit 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 
anterior resin-based composite (D2330), posterior resin-based composite (D2392), two periodontal scalings and 
root planings (D4341 x2), and two gingival irrigations (D4921 x2) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 7, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you have been using this dentist for a long time 
and were never advised that they were OON. You also say that if you had been advised that this provider was 
not in-network, you would have gone to another dentist that was in-network. The Plan denied your request. The 
Plan says services performed by an OON provider are not covered because your healthcare plan does not have 
OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits 
and provider eligibility. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on December 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth, partially bony (D7230), 
removal of an impacted tooth, completely bony (D7241) and incisional biopsy of oral soft tissue (D7286). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of an impacted tooth, partially bony (D7230), removal of an impacted tooth, completely bony (D7241) 
and incisional biopsy of oral soft tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) provided on 
October 18, 2021. 
 
You asked the Plan to pre-approve the removal of residual tooth roots. You say that the Plan was only billed for 
two extractions. You also say that you dispute the Plan's refusal and would like to appeal this. The Plan denied 
your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says 
that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of residual tooth roots (D7250) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided January 10, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to switch dentists 
for an earlier appointment. The Plan denied your request. The Plan says you have exceeded the frequency limit 
for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral evaluation once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on January 5, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral evaluation has been exceeded. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided January 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy services provided from 
April 12, 2021, to April 22, 2021. 
 
You asked the Plan to waive the deductible for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the deductible applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to Outpatient rehabilitation services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time the physical therapy services was received on April 12, 2021, to April 22, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy services 
provided from April 12, 2021, to April 22, 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) provided 
January 24, 2022. 
 
You asked the Plan to pay for the fluoride varnish. You say that you are low income, and the service was done 
in error. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
topical application of fluoride varnish (D1206) provided January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was the nursing facility's responsibility to get 
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 office visit provided on December 22, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can be safely administered at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer may be considered when treatment has completed. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth - partially bony (D7230) 
provided July 7, 2021. 
 
You asked the Plan to pay for the removal of impacted tooth. You say that you were not aware that this type of 
extraction would not be covered. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
removal of impacted tooth - partially bony (D7230) provided July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from March 1, 2021, to October 
18, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the dental services. You say that 3 dentist visits were denied, but they were paid 
in the previous year. You also say that you were not notified that coverage was dropped. The Plan denied your 
request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds. 
The Plan also says that the treating provider opted out of Medicare effective November 22, 2017, to November 
22, 2023. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the dental services provided from March 1, 2021, to October 18, 2021 by a 
Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by a 
participating provider on January 4, 2022. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit for D5214 has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a mandibular 
partial denture once every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D5214 was previously provided 
on August 11, 2021. Based on this information, we decided that the Plan's rules for coverage of a mandibular 
partial denture have already been met. Therefore, we decided that the Plan does not have to pay for a 
mandibular partial denture (D5214) provided by a participating provider on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three prefabricated abutments (D6056 x3) and three 
abutment supported porcelain fused to metal crowns (D6059 x3). 
 
You asked the Plan to pre-approve prefabricated abutment and abutments supported porcelain fused to metal 
crowns. You say that you need the crowns to be covered because you do not have the money to pay for them. 
The Plan denied your request. The Plan says these services are not covered under your benefit 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 pre-approve three 
prefabricated abutments (D6056 x3) and three abutment supported porcelain fused to metal crowns (D6059 x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 26, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were scheduled for a cleaning prior to the 
date of service in this case. You say that you had to cancel due to the coronavirus. You also say that you 
believe that this is why The Plan denied your request. The Plan says cleanings are limited to 2 per 
calendar year. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and cleanings are covered twice per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for cleanings that you received on January 8, 2021, and August 6, 2021. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for 
code 74420. 
 
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 74018 
is a column II code to column I code 74420. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74018 billed for date of service January 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for X-rays of the hand provided on November 
29, 2021. 
 
You asked the Plan to reduce the copayment for the X-rays. You say that a Plan customer service 
representative informed you that it would only be $35. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each standard X-ray service.  
 
You have been asked to pay a $50 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment 
for X-rays of the hand provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on December 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that a provider performing services in a nursing home 
facility is not responsible to obtain authorization. You also say that you believe it is imperative that the Plan 
reimburse the treating provider for the services rendered, to avoid making the patient unfairly responsible for 
the unpaid balance. The Plan denied your request. The Plan says the treating provider is not a network provider 
with the Plan. The Plan also says that 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 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 eye exam (92014) provided on December 20, 
2021 by an out-of-network (OON) provider.