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

 
We decided that the Plan does not have to pay for partial denture sectioning services (D9120) provided on July 
13, 2021. 
 
You asked the Plan to pay for the partial denture sectioning services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for partial 
denture sectioning services (D9120) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) provided on 
July 18, 2022 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. 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 Physician/Practitioner services, including doctors office visits, specifically specialist visits.  
 
 
  You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits, specifically specialist visits 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 specialist office visit (99203) provided on July 18, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial denture (D5225) and the adjustment to partial 
denture (D5421) provided on July 6, 2022, July 8, 2022, and July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you the dental services would 
be covered by the Plan. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the partial denture and adjustments to partial dentures 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 partial 
denture (D5225) and the adjustment to partial denture (D5421) provided on July 6, 2022, July 8, 2022, and July 
18, 2022.
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 did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary. 
All services that would be provided in the LTACH are being provided in the current acute care setting which is 
already approved. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 oral hygiene instructions (D1330), the topical application 
of fluoride (D1206), and the consultation with a medical professional (D9311) provided on April 27, 2021, and 
May 20, 2021. 
  You asked the Plan to pay for the dental services. You say that you were told the dentist was in-network and 
you would like the services paid for. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the oral hygiene instructions, the topical application of fluoride, and the 
consultation with a medical professional 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 the oral 
hygiene instructions (D1330), the topical application of fluoride (D1206), and the consultation with a medical 
professional (D9311) provided on April 27, 2021, and May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for brand name upgrade copayment of $325. We 
decided that the Plan does not have to waive the copayment for base crown (D2740) $425 copayment and 
porcelain upgrade $150 copayment.  
 You asked the Plan to waive the copayment for base crown (D2740), porcelain upgrade and brand name 
upgrade provided on August 5, 2022. You say that you had a crown put on and it was too large, therefore you 
went to have it fixed. You say that you should not have to pay for the new crown. The Plan says that a partial 
refund is being paid directly to you. 
 
We decided that the Plan has to waive the copayment for brand name upgrade copayment of $325.  
 
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 dental booklet and EOC do not indicate there is additional cost-sharing for a brand-name upgrade. The 
Plan has not provided information to support this cost-sharing. 
 
Therefore, we decided that the Plan has to waive the copayment for brand name upgrade copayment of $325.  
 
We also decided that the Plan does not have to waive the copayment for base crown (D2740) $425 
copayment and porcelain upgrade $150 copayment. 
 
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 waive the copayment for base crown (D2740) $425 
copayment and porcelain upgrade $150 copayment. 
 
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 pay for the panoramic radiographic image (D0330) provided on 
August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a dental evaluation done and the 
provider told you that they did not have any x-rays. 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 the date of service of August 9, 2022. 
The Plan paid for the complete series of radiographic images (D0210) on the same date of service. Therefore, 
we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
August 9, 2022.  
 Your complaint about the provider telling you they would not charge for the services is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by an out-of-
network provider on July 7, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you were informed that you would not get 
charged. The Plan denied your request. The Plan says the rendered dental service 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, 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 bone 
replacement graft (D7953) provided by an out-of-network provider on July 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level facet joint injection. 
 
You asked the Plan to pre-approve a third level facet joint injection. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 third level facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request for a 
third level exceeds utilization criteria. Therefore, only 2 levels are deemed medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a third level facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a third level facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Dental service (D0140) has been denied due to the service not being covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 August 3, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal surgery with bone reshaping. 
 
You asked the Plan to pre-approve the requested periodontal surgery. You say that this should be approved. 
The Plan denied your request. The Plan says the criteria for the requested 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 the requested 
periodontal surgery 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 the requested periodontal surgery. Our 
reviewer says that the documentation does not support that the requested services are reasonable and necessary 
or that they meet internal dental criteria. Our physician reviewer found In order to proceed with surgical 
periodontal treatment there must be a record of prior non-surgical periodontal treatment and current status 
following initial treatment.  There are an insufficient number of x-rays provided to assess the posterior 
segments of the mouth. There were two periodontal charts included in the documentation but no documentation as to clinical findings pre and post scaling and root planing to allow for an assessment of the osseous condition. 
Given the lack of information with supporting documentation, there is no medical necessity at this time. 
 
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 the requested periodontal surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve periodontal surgery with bone reshaping.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 83036 and 84443 provided on 
April 21, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing coded 83036 and 84443 provided on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow 
(AQMBF) (CPT code 78434). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational and/or unproven. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found cardiac positron emission tomography (PET) scan for AQMBF would not be considered 
medically reasonable and necessary in this enrollee's clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve absolute quantitation of myocardial blood flow (AQMBF) (CPT code 78434).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) for tooth #16 provided on September 
8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would have never had the service done if 
you knew it was not covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because extractions 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 the 
extraction (D7210) for tooth #16 provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code J2001. The Plan denied your request. The Plan says payment for 
code J2001 is bundled into payment for code 20611. 
 
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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve dental service. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested service is not a covered benefit with your 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 a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and an extraction (D7140), provided by an out-of-network provider on July 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that there would be no 
charge. 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. 
 
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 a limited oral evaluation (D0140), intraoral 
imaging (D0220), and an extraction (D7140), provided by an out-of-network provider on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional 
periapical x-rays (D0230 x 5) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you understand a comprehensive oral evaluation 
is covered once every three years. You say that your previous dentist moved in late 2021. You also say that this 
was to establish care with a new dentist. The Plan denied your request. The Plan says your benefits for the 
comprehensive oral evaluation and periapical x-ray have 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 comprehensive oral evaluation was exhausted on date of service May 8, 2020.The 
record shows your benefit for the periapical x-ray was exhausted on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional 
periapical x-rays (D0230 x 5) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2394), the first periapical x-ray 
(D0220 x2), and the resin-based composite (D2392) provided by an out-of-network provider on June 23, 2022, 
and June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied claims. 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 the resin-based composite (D2394), the first periapical x-ray (D0220 x2), and the resin-based 
composite (D2392) provided by an out-of-network provider on June 23, 2022, and June 27, 2022.