Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on August 24, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $35 
copayment for Urgently needed services. 
 
You have been asked to pay a $35 copayment for urgent care visit. This item/service falls within the Urgently 
needed services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for urgent care visit provided 
on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should have been aware that these 
codes are only allowed every three years and you should not be responsible. The Plan denied your request. The 
Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service September 24, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and panoramic radiographic image (D0330) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for a resin-based composite - one surface, posterior 
tooth #28 (D2391) provided on July 25, 2022. 
 
You asked the Plan to pay the full cost for the resin-based composite - one surface, posterior tooth #28 
(D2391). You say that you are disputing the $20 difference in the allowed amount as you believe the least 
costly method is outdated and not used by any provider. The Plan denied your request. The Plan says the claim 
was processed correctly in accordance with your dental plan 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.  
 
Therefore, we decided that the Plan does not have to pay the full cost for a resin-based composite - one surface, 
posterior tooth #28 (D2391) provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 10, 
2021. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87632 and 87634 billed for date of service 
March 1, 2022. 
 
You asked the Plan to pay for procedure code 87634. You say that the charges should be allowed. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
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 87634 is a column II code to column I code 87632. Code 87634 has 
not been billed with an appropriate modifier to bypass the edit. The file also shows that code 87632 was not 
ordered by the enrollees treating physician. Based on this information, we have decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 87632 and 87634 billed for date of service March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that your old dentist never sent your x-rays to your 
new dentist. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 3, 2022. Therefore, 
we decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), and bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regeneration, per site 
(D4265), and bone replacement graft for ridge preservation - per site (D7953). You say that you do not have 
the $800 that you are being charged for the implant services. The Plan denied your request. The Plan says these 
services are not covered under the 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 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and bone replacement graft 
for ridge preservation - per site (D7953).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and Stryker Vitross Allograft 
services. 
 
You asked the Plan to pre-approve bone marrow aspirate and Stryker Vitross Allograft services. You say that 
these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the requested services are considered experimental/investigational. 
 
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 bone marrow aspirate and Stryker 
Vitross Allograft services. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee is a 75-year-old female was 
being treated for intervertebral disc displacement of the lumbar region. She presented with ongoing, fairly severe low back pain. She is frustrated with the ongoing symptoms. The exam reveals some restricted lumbar 
motion with end-range discomfort. Strength and sensation are intact. 
  
In this case, there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate or Vitross allograft for this enrollees medical condition as discussed above. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested bone marrow aspirate and Stryker Vitross Allograft 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 bone marrow aspirate and Stryker Vitross Allograft services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate and Stryker Vitross 
Allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) provided by a 
participating provider. 
 
You asked the Plan to pre-approve scaling and root planing. You say that these services are medically 
necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 scaling and 
root planing when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve scaling and root planing. Our physician 
reviewer found documentation provided does not meet the criteria for coverage for scaling and root planing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of scaling and root planing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve scaling and root planing (D4341) provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 40814 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code remains 
not supported. 
 
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 40814 is excision of lesion of mucosa and submucosa, 
vestibule of mouth; with complex repair. We asked our coder to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the billed 
services. Our reviewer found that the procedure report does not describe, an excision of a lesion or area of 
damaged or diseased tissue of the mucosa, a membrane lining the anterior most part of the mouth, and the 
submucosa, the layer beneath the mucosa. This procedure involves complex repair of the surgical 
wound. Therefore, the code cannot be verified, as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 40814 billed for date of service June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 20, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $395 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
 You have been asked to pay $395 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 waive the 
copayment for outpatient surgery provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5130, D5214) provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your $500 benefit maximum allowance for the 
requested item or service 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 15, 2021. 
Therefore, we decided that the Plan does not have to pay for dentures (D5130, D5214) provided on December 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 11, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 23, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision placement (D6191 and D6192) provided 
by a participating provider. 
 
You asked the Plan to pre-approve semi-precision placement. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the services have been correctly denied. 
 
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, D6192 is not among those covered 
under this benefit. D6191 has already exhausted. Therefore, we decided that the Plan does not have to pre-
approve semi-precision placement (D6191 and D6192) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction of tooth #3 and 15 (D7210) provided on 
April 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the processing of this 
claim. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. The Plan also 
says that you have been charged the correct cost sharing amount. 
 
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. 
 
You have been asked to pay $54.45, which is 55% coinsurance of the allowed amount for each extraction ($99 
allowed amount x 55% coinsurance = $54.45.) You have also been asked to pay the difference between the out-
of-network providers charges and the Plans payment. 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 pay more for the 
extraction of tooth #3 and 15 (D7210) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic image (D0220) and to pay 
for the limited oral evaluation (D0140), the preventative procedure (D1999), and a crown (D2920) for tooth #8 
provided by on July 5, 2022. 
 
You asked the Plan to pay more for the intraoral radiographic image and to pay for the limited oral evaluation, 
the preventative procedure, and the crown. You say that the dental procedures were an emergency, and you did 
not know the dental procedures would not be covered. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Also, the denial of payment for the limited oral evaluation, the preventative 
procedure, and the crown is correct, because they are not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the intraoral radiographic image (D0220) 
and to pay for the limited oral evaluation (D0140), the preventative procedure (D1999), and a crown (D2920) 
for tooth #8 provided by on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you consider the denial a default in the contract 
to provide the services. You say that the summary of benefits is mis-leading. The Plan denied your request. The 
Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided on 
June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you had two root canals, so your old 
dentures do not fit properly. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 20, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5214) provided 
by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on May 11, 2022.

You asked the Plan to pay for the testing services. You say that the claim was underpaid. The Plan denied your request. The Plan says the testing 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. We find that the testing described by code 83789 is considered specimen validity testing which is not separately payable. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) and the 
application of desensitizing medicament (D9910) provided on May 25, 2022. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused (D0140) and the application of 
desensitizing medicament (D9910). You say that you were having pain for two weeks and the treatment 
worked. You also say that you think the treatment should be paid for. The Plan denied your request. The Plan 
says the member is responsible for paying the full cost of services that are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation - problem focused (D0140) and the application of desensitizing medicament (D9910) provided 
on May 25, 2022.