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

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents, per tooth 
(D4381 x 7), gingival irrigation (D4921 x 4), and other drugs or medicaments (D9630) provided from May 25, 
2022, to May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you spend $661 for a cleaning. You say that you 
should be partially reimbursed. The Plan denied your request. The Plan says the services are not listed as 
covered dental services. 
 
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 localized deliver of antimicrobial 
agents, gingival irrigation, and other drugs or medicaments are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents, per 
tooth (D4381 x 7), gingival irrigation (D4921 x 4), and other drugs or medicaments (D9630) provided from 
May 25, 2022, to May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. 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 you do not meet the requirements for them, x-rays are indicative of gingivitis (not periodontitis), 
which is treatable for a dental cleaning. 
 
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 
periodontal scaling and root planing (D4341)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) and pulp vitality tests (D0460) 
provided May 3, 2022. 
 
You asked the Plan to pay for the cone beam CT scan and pulp vitality tests. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services are not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 cone beam computed tomography (CT) capture and interpretation with limited field of view  less than one whole 
jaw (D0364) and pulp vitality tests (D0460) provided May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305) provided on October 12, 
2021. 
 
You asked the Plan to pay for code 88305. You say that you would like the plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removeable mandibular denture 
(D6111), endosteal implants on tooth #22 and 27 (D6010), prefabricated abutments on tooth #22 and 27 
(D6056), and bone grafts on tooth #22 and 27 (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says an implant supported removeable mandibular denture (D6111), 
endosteal implants (D6010), prefabricated abutments (D6056), and bone grafts (D6104) are not covered by the 
enrollee's 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 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 an 
implant supported removeable mandibular denture (D6111), endosteal implants on tooth #22 and 27 (D6010), 
prefabricated abutments on tooth #22 and 27 (D6056), and bone grafts on tooth #22 and 27 (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry services provided on March 8, 
2022. 
 
You asked the Plan to waive the deductible for the podiatry services. You say that you were charged a lower 
amount for a previous visit. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $200 deductible which applies to certain items and services.  
 
The podiatry services fall within the Podiatry Services benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $200 deductible which applies to certain items and services. 
This cost sharing is a contractual obligation that had not been met at the time the podiatry services were 
received on March 8, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
podiatry services provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 
27, 2021. 
  You asked the Plan to pay for procedure code 93010. You say that the medical records support the claim as 
originally billed and no coding changes are required. The Plan denied your request. The Plan says payment for 
code 93010 is bundled into payment for code 12001. 
 
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 93010 
is a column II code to column I code 12001. 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 93010 billed for date of service September 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided November 15, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you feel that the additional 
periodontal check should not negate your standard cleaning. The Plan denied your request. The Plan says this 
service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation - new or established patient (D0180) provided November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) 
 
You asked the Plan to pre-approve the maxillary complete denture. 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 pre-approve a 
maxillary complete denture (D5110)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9943) provided on March 2, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item 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 an 
occlusal guard (D9943) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with the out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services received from an out-of-network 
provider are not covered by your supplemental benefits. There are in-network dental providers available.  
 
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, dental 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 dental services with the 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns on tooth #7, 8, 9, 10, 11, 12, and 13 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that crowns (D2740) are not covered by 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 pre-approve 
crowns on tooth #7, 8, 9, 10, 11, 12, and 13 (D2740).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on November 24, 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 procedure codes 95939, 95907, and 95885 are 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 95939 is central motor evoked potential study 
(transcranial motor stimulation); in upper and lower limbs. The definition of code 95907 is nerve conduction 
studies; 1-2 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure). 
 
We find that CPT codes 95939, 95907, and 95885 are not supported in the medical record. Specifically, there is 
no documentation of a central motor evoked potential study in the upper and lower limb to support code 95939. 
There is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation 
of needle electromyography with nerve conduction to suport code 95885. 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 pay for the testing services rendered on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown for tooth# 12 (D2740) provided 
on May 23, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this dental item was 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 a dental 
crown when 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 pay for this item. Our reviewer says that the dental 
crown provided was not medically necessary. Our physician reviewer found that the enrollee did not meet 
criteria for coverage of a dental crown. The radiographs provided were not of a diagnostic quality to verify the 
need for the service. 
  
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plan's rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pay for the porcelain/ceramic crown for tooth# 12 (D2740) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) provided on November 1, 
2021. 
 
You asked the Plan to pay for code 99220. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are 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 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99220 is not supported in the medical record. Specifically, the medical records 
submitted do not support that medical decision making of high complexity for a diagnosis of a urinary tract 
infection was made. Based on this information, we decided that Medicare rules for coverage of code 99220 
have not been met. Therefore, we decided that the Plan does not have to pay for the initial observation care 
(99220) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) 
 
You asked the Plan to pre-approve the bone replacement graft. 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 pre-approve a 
bone replacement graft (D4263)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on February 28, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you would 
like to appeal these 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 December 9, 2020, and 
July 28, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) and panoramic x-ray (D0330) provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus palatinus and alveoloplasty 
(D7472, D7310) 
 
You asked the Plan to pre-approve the removal of torus palatinus and alveoloplasty. 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 pre-approve the 
removal of torus palatinus and alveoloplasty (D7472, D7310)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) for an approved 
power wheelchair with related electronic connections (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the expandable controller and related items. You say that you feel that the 
requested items should be approved. The Plan denied your request. The Plan says the wheelchair was approved, 
but the expandable controller is not medically necessary. 
 
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 expandable controller and related 
items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches that are included with these options. 
 
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 expandable controller and related items have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377) for an approved power 
wheelchair with related electronic connections (E2311) and harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of the limit on this benefit 
and cannot afford the cost. 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 July 31, 2021. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) and the 
chiropractic manipulative treatment (98941) provided on February 23, 2021 and March 3, 2021. 
 
You asked the Plan to issue reimbursement for these services. 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 at 
issue are not payable as the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until March 28, 2022. This means that more than 
one calendar year from the dates of service at issue had passed before a claim was filed. Therefore, we decided 
that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) and the chiropractic 
manipulative treatment (98941) provided on February 23, 2021 and March 3, 2021.