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

 
We decided that the Plan does not have to pre-approve partial lower dentures (D5214) and partial upper 
dentures (D5213). 
 
You asked the Plan to pre-approve dentures. You say that your previous dentures are 20 years old, and it is 
necessary for you to have replacements due to having additional teeth removed. The Plan denied your request. 
The Plan says dentures are not covered by your dental 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 pre-approve 
partial lower dentures (D5214) and partial upper dentures (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the periodic oral evaluations (D0120) 
provided on March 1, 2021, and September 7, 2021. 
You asked the Plan to pay an additional amount for the dental exams. You say that you did not know this 
provider was out-of-network. The Plan denied your request. The Plan says these claims were processed 
correctly according to 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. The rules also 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 are responsible for 50% coinsurance for 
periodic oral exams performed by out-of-network providers. Network dentists have agreed to provide services 
at a negotiated rate. If you see a network dentist, you cannot be billed more than that rate for covered services. 
Benefits received out-of-network are subject to any in-network benefit maximums, limitations and/or 
exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made 
by the Plan to the provider. 
 
The provider in this case is not part of the Plans dental network. It is your responsibility to contact the Plan to 
verify provider eligibility. The record shows that the provider billed the Plan $46 for each of the periodic oral 
exams. The Plans allowed amount for this service is $26 per exam. This is the amount that in in-network 
provider would accept as full payment for this service; however, out-of-network providers do not have this 
agreement with the Plan and are allowed to bill you the difference between the Plans rate and the full billed 
amount ($46 - $26 = $20). In addition, you are responsible for 50% coinsurance for periodic oral evaluations 
performed by an out-of-network provider. Coinsurance is always calculated from the Plans allowed rate ($26 x 
50% coinsurance = $13). You have been asked to pay $33 for each of these exams ($20 + $13 = $33). 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 pay an additional amount for the periodic oral evaluations (D0120) provided on 
March 1, 2021, and September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided December 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the root canal. You say that you never received a list of in-network providers. 
The Plan denied your request. The Plan says service provided OON are not covered. 
 
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. The Plan covers the root canal 
when provided in-network.  
 
We looked at the file, and Medicare rules. The requested provider in this case is not a network provider with 
the Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided December 7, 2021, by an out-
of-network (OON) provider.  
 
Your complaint about potentially not receiving a list of network providers 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 the porcelain/ceramic crown (D2740) provided on June 8, 2021. 
 
You asked the Plan to pay for the crown. You say that crowns were covered with your 2020 Plan, and other 
competitive plans offer crowns with dental coverage. The Plan denied your request. The Plan says crowns are 
not covered by your dental benefit. 
 
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 the 
porcelain/ceramic crown (D2740) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210) provided on January 4, 2022. 
 
You asked the Plan to pay for the surgical extractions. You say that you would like this service to be covered. 
The Plan denied your request. The Plan says this service is not a covered expense 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 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 the 
surgical extractions (D7210) provided on January 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT. You say that you need additional therapy to fully build your 
strength. The Plan denied your request. The Plan says they have agreed to approve 6 additional physical 
therapy visits; however, the other six visits requested (for a total of 12) are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional PT. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the requested additional therapy generally is not accepted as 
specific and effective therapy for your condition. You have had prior PT, and the documentation does not 
reveal that you require the unique skills of a professional therapist to safely and effectively provide treatment, 
or that the services can be safely and effectively performed only by a therapist, or by or under the supervision 
of a therapist. You have been instructed in a home exercise program. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on April 17, 2021. 
 
You asked the Plan to pay for code 83789. 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. 
 
In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated 
is not separately billable. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry 
and tandem mass spectrometry (83789) provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider November 
11, 2021. 
 
You asked the Plan to pay for dental services. You say that these services are not medically necessary. The 
Plan denied your request. The Plan says the rendering dentist has opted-out of 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 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 until August 18, 2021. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on December 16, 2021. 
 
You asked the Plan to pay for the consultation. You say that the dentist said they could not help you and told 
you to go to the hospital. You also say that you were surprised to get a bill from the dental office for a 
consultation. The Plan denied your request. The Plan says this service is not a covered expense 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 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 the 
consultation (D9310) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010), prefabricated abutments  includes modification and placement (D6056), and implant supported 
porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments and implant supported 
crowns. You say that you need these services. 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 pre-approve surgical placement of implant body: endosteal implants (D6010), prefabricated abutments  includes 
modification and placement (D6056), and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 14, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan and were told dentures 
were not covered but extractions were. You also say that the agent never told you the treating provider was 
OON. The Plan denied your request. The Plan says services performed by an OON provider are not covered 
because your healthcare plan does not have OON benefits. The Plan says that you did call and were offered 
benefit information, but did not go over extractions, only denture coverage, and you were sent a copy of your 
coverage. The Plan also says that you were offered the option for the associate to review the provider multiple 
times, but you declined. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the dental services provided on September 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten prefabricated abutments (D6056 x10) and ten 
implant supported porcelain/ceramic crowns (D6065 x10). 
 
You asked the Plan to pre-approve the prefabricated abutments and implant supported porcelain/ceramic 
crowns. You say that you feel uncomfortable when chewing with your back teeth. The Plan denied your 
request. The Plan says these services are not covered under your benefit plan. 
 
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 pre-approve ten 
prefabricated abutments (D6056 x10) and ten implant supported porcelain/ceramic crowns (D6065 x10).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering described by code 
L5962 for an approved leg prosthesis. 
 
You asked the Plan to pre-approve the L5962 covering. You say that all requested items are medically 
necessary and should be approved. The Plan denied your request. The Plan says the prosthesis has been 
approved; however, the specialized protective covering is not shown to be required. 
 
The Plan follows Medicare rules. Medicare rules say that an outer covering described by L5962 may be 
covered for enrollees requiring protection from unusually harsh environmental conditions.  
 
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 L5962 covering. Our reviewer says 
that the requested L5962 covering is not considered medically necessary in this case. Our physician reviewer 
found the provided documentation does not describe the patient being in a harsh environment that might require a protective outer surface covering to justify this request. Therefore, this request for the flexible 
protective outer surface covering system will be considered not medically necessary at this time.   
 
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 L5962 covering have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a protective outer surface covering described by code L5962 for an approved leg 
prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), implant supported porcelain/ceramic crown (D6065) and prefabricated abutment - includes 
modification and placement (D6056). 
 
You asked the Plan to pre-approve an endosteal implant, implant supported crown and prefabricated abutment. 
You say that you would like these services covered. 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 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 pre-approve 
surgical placement of implant body: endosteal implant (D6010), implant supported porcelain/ceramic crown 
(D6065) and prefabricated abutment - includes modification and placement (D6056).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that the codes billed support medical necessity. 
The Plan denied your request. The Plan says the codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 76000 is fluoroscopy (separate procedure), up to 1 hour 
physician or other qualified health care professional time. The medical records provided do not show that the 
service billed with the -59 modifier is a distinct procedural service. Services integral to accomplishing a 
procedure are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code. 
 
the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician 
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness. We find that CPT code 99152 is not supported in the medical record. The records do 
not show that the services required the presence of an independent trained observer.  
 
The CPT Code Manual definition of code 92921 is percutaneous transluminal coronary angioplasty; each 
additional branch of a major coronary artery (List separately in addition to code for primary procedure). We 
find that 92921 is a bundled code. When these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgery services provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 7, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that the Plan did not inform the doctor's office that this 
service would not be covered. You also say that the provider was as shocked as you are to learn that the Plan 
does not have scheduled coverage for cleanings two times per year. The Plan denied your request. The Plan 
says your benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, prophylaxis is limited to one procedure 
code per calendar year. The record shows that you received a prophylaxis (D1110) on February 3, 2021 and 
your prophylaxis benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sacroiliac joint injection of the right side 
(27096, G0260). 
 
You asked the Plan to pre-approve a repeat sacroiliac joint injection of the right side. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for the requested service have not been met. 
 
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 a repeat sacroiliac joint injection of the 
right side. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that records document a decrease in the enrollee's right-sided pain from 
a 9 out of 10 to a 5 to 6 out of 10 from the prior injection. Records do not document initial pain relief from the right side injection of greater than or equal to 75% - 100% and the ability to perform previously painful 
maneuvers. 
 
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 repeat sacroiliac joint injection of the right side have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a repeat sacroiliac joint injection of the right side 
(27096, G0260).