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

 
We decided that the Plan does not have to provide additional payment for the extractions, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), 
removal of residual tooth roots (cutting procedure) (D7250), alveoloplasty in conjunction with extractions - 
four or more teeth or tooth spaces, per quadrant (D7310) and consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided December 10, 2021. 
 You asked the Plan to provide additional payment for the tooth extractions, removal of residual tooth roots, 
alveoloplasty, and dental consultation. You say that you would like these services covered. The Plan denied 
your request. The Plan says these services have processed correctly according to 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 unlimited 
extractions per calendar year with 50% coinsurance and 2 oral surgery codes per calendar year with 70% 
coinsurance. 
 
We looked at the file and Medicare rules. The Plan has determined that the extractions coded as D7210 are 
more appropriately represented by D7140 and have been processed as such. You have been asked to pay 50% 
of the cost of each extraction according to your Plan benefits. Additionally, you have been asked to pay 70% of 
the cost of two alveoloplasty according to your oral surgery benefit. The remaining alveoloplasty as well as the 
removal of residual roots have been denied as these services exceed your frequency limit for oral surgery. 
Based on this information, we decided that the Plan's rules for coverage of the tooth extractions, removal of 
residual tooth roots, alveoloplasty, and dental consultation have not been met. Though the Plan offers dental 
benefits in excess of Medicare coverage, the dental consultation is not among those covered services. 
Therefore, we decided that the Plan does not have to provide additional payment for the extractions, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), 
removal of residual tooth roots (cutting procedure) (D7250), alveoloplasty in conjunction with extractions - 
four or more teeth or tooth spaces, per quadrant (D7310) and consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (code D0140) or waive the cost 
share for a routine extraction (tooth # 9, #10) (code D7140) provided on March 2, 2022. 
 You asked the Plan to pay for an evaluation and waive the cost share for an extraction. You say that you want 
the bill you received for $160 to be re-evaluated. The Plan denied your request. The Plan says a limited oral 
evaluation is not covered by the Plan. The Plan also says that you have been charged the correct cost sharing 
amount for the extractions. 
 
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 oral evaluation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (code D0140) provided on March 2, 2022.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Plan contract also says that there is a $50 dental deductible for 
comprehensive dental services every year. The contract says there is a $2,000 maximum allowance with 50% 
coinsurance after the deductible is met every year for comprehensive dental services. 
 
You have been asked to pay a total of $55 for an extraction (tooth #9). The comprehensive dental services 
deductible was not met at the time of service; therefore, $50 was applied to satisfy the deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $50 deductible for comprehensive 
dental services. This cost sharing is a contractual obligation that had not been met at the time of the extraction 
(tooth #9). 
 
The allowed amount remaining after you paid the deductible is $10 ($60 original allowed amount - $50 
deductible paid = $10 remaining allowed amount). You have been asked to pay $5, which is 50% coinsurance 
of the remaining allowed amount for an extraction (tooth #9) ($10 remaining allowed amount x 50% 
coinsurance = $5).  
 
You have also been asked to pay $30, which is 50% coinsurance of the allowed amount for an extraction (tooth 
#10) ($60 allowed amount x 50% coinsurance = $30). An extraction falls within the Dental 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 the plan does not have to waive the cost share for the routine extractions (tooth #9, #10) (code D7140) 
provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomics testing provided on 
October 5, 2021. 
 
You asked the Plan to pay for the comprehensive pharmacogenomics testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This testing is an NGS procedure evaluating multiple genes and was 
not billed with a single panel code as required. Based on this information, we decided that Medicare rules for 
coverage of the comprehensive pharmacogenomics testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the comprehensive pharmacogenomics testing provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intra-orally photographic images (code D0350) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the images. You say that you thought you were getting routine x-rays and a 
cleaning. You also say that you were unaware these x-rays were not covered. The Plan denied your request. 
The Plan says intra-orally photographic images 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 intra-
orally photographic images (code D0350) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) and the 
extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on 
January 31, 2022. 
 You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not a covered benefit by the 
Plan as they were rendered by an out-of-network provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The Plan contract says that payment cannot be made 
for Medicare covered services rendered by a provider who has opted-out of Medicare.  
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to issue 
reimbursement for the limited oral evaluation (D0140) and the extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced prosthetic endoskeleton alignable system. 
 
You asked the Plan to pre-approve these services. 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 that prosthetic additions are covered when specific 
criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found Medicare allows for replacement of a 
prosthesis or prosthetic component if there is a change in the physiological condition of the beneficiary, there is 
irreparable wear of the device or a part of the device or if the condition of the device, or part of the device, 
requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or the 
part being replaced. The documentation does not support that the existing alignable endoskeletal system is 
beyond repair and cannot be used for the approved replacement prosthesis. 
 
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 advanced prosthetic endoskeleton alignable system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services performed on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you do not recognize the name of 
the provider. 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 $325 
copayment per visit for surgery or other services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for the wound care. The wound care falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 wound care services performed on February 17, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you believe this should have been paid 
by insurance. 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 $195 
copayment for diagnostic radiology services, including MRI's.  
 
You have been asked to pay a $195 copayment for the MRI. The MRI falls 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 waive the copayment 
for a magnetic resonance imaging (MRI) of the brain provided on December 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional hours of home health aide services. 
 
You asked the Plan to pre-approve 36 additional hours for home health aide services. You say that the enrollee 
does not have the cognitive ability to fully understand the information regarding their insulin needs. You say 
that the enrollee does not have financial resources to move to a higher level of care. You also say that the 
enrollee does not have a caregiver to administer her insulin and cannot do it on her own. The Plan denied your 
request. The Plan says the enrollee does not have any skilled nursing needs. The Plan also says that home 
health aide services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.   
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 36 additional hours for home health 
aide services. Our reviewer says that 36 additional home health aide hours are not medically necessary. Our 
physician reviewer found daily, home health, skilled nurse services are being requested. The reviewer found 
that your health plan has approved intermittent services. Therefore, the reviewer found that additionally home 
health aide hours are not medically necessary, reasonable or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36 additional hours for home health aide services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 36 additional hours of home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic imaging (code D0350) and cone 
beam imaging (code D0367) provided on March 1, 2022. 
 
You asked the Plan to pay for the imaging. You say that you were not told there would be extra charges. The 
Plan denied your request. The Plan says that the photographic and cone beam imaging are 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 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 oral/facial photographic imaging (code D0350) 
and cone beam imaging (code D0367) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on November 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. Billed procedure codes S1015 and S8301 have a status indicator of I 
and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the 
supplies rendered on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first periapical x-ray (D0220) and the core build-up 
(D2950) provided by a network provider on February 9, 2022. 
 
You asked the Plan to pay for the first periapical x-ray (D0220) and the core build-up (D2950). You say that 
you missed your routine cleanings due to the pandemic. You say as a result, you needed two root canals and 
you are requesting that the limitation be excused. The Plan denied your request. The Plan says the benefits 
were applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build-up (D2950) is not 
among those covered under this benefit. The Plan also has a maximum benefit of one periapical x-ray every 
three years. The requested service is not covered because the Plan paid for an additional periapical x-ray on 
February 9, 2022, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 
the first periapical x-ray (D0220) and the core build-up (D2950) provided by a network provider on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), the gingival 
irrigation (D4921), and the medications dispensed in-office for home use (D9630) provided by a network 
provider from January 29, 2021, to February 9, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test (D0431), the gingival irrigation (D4921), and 
the medications dispensed in-office for home use (D9630). You say that the provider billed the services on all 
one claim when it should have been billed on two claims. You say you have already paid $128. The Plan 
denied your request. The Plan says the services are not covered benefits.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the adjunctive pre-diagnostic test 
(D0431), the gingival irrigation (D4921), and the medications dispensed in-office for home use (D9630) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431), the gingival irrigation (D4921), and the medications dispensed in-office 
for home use (D9630) provided by a network provider from January 29, 2021, to February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for the dental implants (dental codes D6010, 
D6011, D6058, D6104, and D6190) provided on March 25, 2021, August 23, 2021, and December 7, 2021. 
 
You asked the Plan to reimburse payment for the dental implants. You say that the provider decided to go with 
an implant instead of a bridge. The Plan denied your request. The Plan says the denial to reimburse for this 
service is correct, because dental implants are not listed in the table of covered benefits, and 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. 
 
  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 reimburse 
payment for the dental implants (dental codes D6010, D6011, D6058, D6104, and D6190) provided on March 
25, 2021, August 23, 2021, and December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom abutment (D6057) and abutment supported 
porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the custom abutment and crown. You say that the service is medically 
necessary. The Plan denied your request. The Plan says these are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
custom abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental crowns (D2750) provided by an out-of-network provider on 
March 1, 2022. 
 
You asked the Plan to pay for dental crowns. You say that these services were medically necessity. The Plan 
denied your request. The Plan says that the crowns that were provided were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide dental x-rays. Dental x-rays are needed in-order to 
verify medical necessity. Therefore, we decided that the Plan has to pay for dental crowns (D2750) provided by 
an out-of-network provider on March 1, 2022.  
 
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.