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

 
We decided that the Plan does not have to pay for topical application of fluoride (D1208) and oral hygiene 
instructions (D1330) provided on June 14, 2022. 
 
You asked the Plan to pay for the fluoride application and hygiene instructions. You say that you have always 
been told you have full dental coverage. The Plan denied your request. The Plan says the services provided are 
not covered benefits under your dental plan.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 topical 
application of fluoride (D1208) and oral hygiene instructions (D1330) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental item. You say that the mouth guards at the store do not fit your 
mouth. You say that you grind your teeth really bad. You also say that you have tried other alternatives but 
none of them are working. The Plan denied your request. The Plan says occlusal guard is not listed as a covered 
dental 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 requested occlusal guard is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the crown (D2740) on tooth #8. We decided that the Plan does not have 
to pay for the crown (D2740) on tooth #9.  
 
You asked the Plan to pay for the crowns (D2740) on tooth #'s 8 and 9 provided on August 4, 2021. You say 
that this was a necessary procedure, and you feel it is wrong for the Plan to deny payment. The Plan says that a 
clinical review of the documentation submitted for the crown on tooth #8 shows the services does not meet the 
criteria for coverage. The Plan also says that your benefits for the crown on tooth #9 have been satisfied and the 
frequency limitation has been exceeded. 
 
We decided that the Plan has to pay for the crown (D2740) on tooth #8.  
 
Medicare rules say that a contract provider is an agent of the Plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the crown (D2740) on tooth #8 by a contract provider. The file does not show that the 
Plan provided notice that the crown (D2740) on tooth #8 would not be covered. The 2021 Evidence of 
Coverage also does not clearly state that any criteria need to be met in order for the crown to be covered. Under 
Medicare rules, this means the crown (D2740) on tooth #8 is considered approved by the Plan. Therefore, we 
decided that the Plan has to pay for the crown (D2740) on tooth #8.  
 
We also decided that the Plan does not have to pay for the crown (D2740) on tooth #9. 
 
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. We have told 
the Plan that they must pay for the crown (D2740) on tooth #8 provided on August 4, 2021, and your crowns 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on 
tooth #9. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival irrigation (D4921) and application of 
desensitizing medicament (D9910). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are a necessity for 
your care. The Plan denied your request. The Plan says your benefit for gingival irrigation has already been 
exhausted and that application of desensitizing medicament is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for gingival irrigation is exhausted because the Plan has approved two instances of this 
service under an authorization effective September 6, 2022. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested application of desensitizing medicamnet is not among the services covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve a gingival irrigation 
(D4921) and application of desensitizing medicament (D9910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87798, and 87801 
billed for date of service November 15, 2021. 
 You asked the Plan to pay for procedure codes 87481, 87640, 87653, 87798, and 87801. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87481, 87640, 
87653, and 87798 are bundled into payment for code 87801 and 87150. 
 
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 codes 
87481, 87640, 87653, and 87798 are a column II code to column I code 87801 and 87150. This claim has not 
been billed with an appropriate modifier to bypass the edit.  
 
We find that CPT code 87801 is not supported in the medical record. Specifically, this code represents multiple 
organisms. The medical records submitted did not indicate which organisms are represented by the billed code. 
The submitted medical records do not support that a repeat clinical laboratory test was performed. Therefore, 
the billed code, units and appropriate use of the 91 modifier cannot be verified. 
 
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 codes 87481, 87640, 87653, 87798, and 87801 billed for date of service 
November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
October 16, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 We find that CPT code 88305 is not supported in the medical record. Specifically, payment for this service is 
included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage 
of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgical pathology services coded 88305 provided on October 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D0150, D7210) to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that the requested services are a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for dental services have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. In this case, the requested services are to be provided by an oral 
surgeon, not a general dentist. Based on this information, we decided that the Plan's rules for coverage of dental 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services 
(D0150, D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #18 (D2740). We also decided that the Plan does 
not have to pre-approve core build up on tooth #18 (D2950), anesthesia (D9211), mouth pictures (D0350), and 
tooth molds (D0470).  
 
 You asked the Plan to pre-approve core build up, anesthesia, pictures, and molds. You say that the tooth is 
worth saving and a crown is medically necessary. The Plan denied your request. The Plan says that tooth #18 
does not have 50% bone support. The Plan also says that core build up (D2950), anesthesia (D9211), mouth 
pictures (D0350), and tooth molds (D0470) are not covered by the enrollee's dental benefits. 
 
We decided that the Plan has to pre-approve a crown on tooth #18 (D2740).  
 
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 service is 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 a crown. Our reviewer says that the 
coverage criteria for a crown has been met. Our physician reviewer found that a crown restoration is medically 
reasonable and necessary to provide adequate masticatory function. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #18 (D2740). 
 
We also decided that the Plan does not have to pre-approve core build up on tooth #18 (D2950), 
anesthesia (D9211), mouth pictures (D0350), and tooth molds (D0470). 
 
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, core build up, anesthesia, mouth 
pictures, and tooth molds are not among those covered under this benefit.   Therefore, we decided that the Plan 
does not have to pre-approve core build up (D2950), anesthesia (D9211), mouth pictures (D0350), and tooth 
molds (D0470). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided from April 9, 2021, 
to May 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not covered. 
 
The file shows that the enrollee received massage therapy services. The Plan must follow Medicare rules. 
Medicare does not cover the services of a massage therapist. The enrollee also received infrared services. 
Medicare rules say that the use of infrared therapy devices and any related services are not medically necessary 
and not covered. Therefore, we decided that the Plan does not have to pay for the pain management services 
provided from April 9, 2021, to May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate is experimental. More research is needed to show safety and efficacy when used as bone graft material. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the bone replacement graft for ridge 
preservation - per site (D7953), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth 
and including elevation of mucoperiosteal flap if indicated (D7210), resin-based composites - three surfaces, 
posterior (D2393) and maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) provided December 10, 2021. 
 
You asked the Plan to provide additional payment for the bone replacement graft, tooth extraction, fillings and 
upper partial denture. You say that you thought your $2,000 allowance would apply toward the claim and were 
not aware that it would not be covered under your policy. The Plan denied your request. The Plan says the 
fillings and extractions have processed correctly with 50% coinsurance. The bone replacement graft and partial 
denture 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. The Plan covers the tooth 
extraction and fillings with 50% coinsurance.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have been asked 
to pay 50% coinsurance for the filling and tooth extraction. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Though the Plan offers dental benefits in excess of Medicare 
coverage, the bone replacement graft and fillings are not among those covered services. Therefore, we decided 
that the Plan does not have to provide additional payment for the bone replacement graft for ridge preservation 
- per site (D7953), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210), resin-based composites - three surfaces, posterior 
(D2393) and maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) provided December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins 
when required (D2950) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says dental 
services rendered by an OON provider 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. 
 
You are requesting dental services from an OON 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 
OON provider. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core 
buildup, including any pins when required (D2950) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and crown (D2750) provided on 
September 29, 2021, periodontal scaling and root planing (D4342 X 2) provided on November 29, 2021, and 
extraction, erupted tooth  (D7210 X 2) provided on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that maybe the charges can be transferred to your 
medical plan. The Plan denied your request. The Plan says the services provided are 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 core 
buildup (D2950) and crown (D2750) provided on September 29, 2021, periodontal scaling and root planing 
(D4342 X 2) provided on November 29, 2021, and extraction, erupted tooth  (D7210 X 2) provided on 
December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222) and 
intravenous moderate (conscious) sedation (D9239). 
 
You asked the Plan to pre-approve sedation and anesthesia. You say that you cannot be put under local 
anesthesia. The Plan denied your request. The Plan says these services are 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 pre-approve deep 
sedation/general anesthesia (D9222) and intravenous moderate (conscious) sedation (D9239).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amalgam filling (D2140) and a crown (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you have been seeing this dentist for many 
years. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve an 
amalgam filling (D2140) and a crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is needed due to paroxysmal atrial 
fibrillation. The Plan denied your request. The Plan says that records do not show that the enrollee has an 
irregular heart rhythm that requires monitoring. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has a 
history of documented atrial fibrillation for which he is being anticoagulated. As such, based on current 
guidelines and the documentation provided, there is insufficient clinical evidence to support the medical 
appropriateness and necessity of replacing the patients old ILR with a new ILR. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided August 30, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that you had difficulty finding someone who 
could extract your teeth due to complications. The Plan denied your request. The Plan says this service is not 
covered because the provider has opted out of Medicare. 
 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 dental 
consultation when you see any licensed dental provider who accepts Medicare patients in the United States and 
has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the dental consultation have not been met. Therefore, we 
decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided August 30, 2021.