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

 
We decided that the Plan does not have to pay for the core build up (D2950) provided on September 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel this should be covered. You also say 
that you were advised you would have help with this. The Plan denied your request. The Plan says core build 
up is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950) provided on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and to pay more 
for the bitewing x-rays (D0272), and prophylaxis (D1110) provided on October 13, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation or pay more for the bitewing x-rays, and 
prophylaxis. You say that the receptionist verified that the treating provider was in-network and that the 
services would be paid in full. You also say that you are on a fixed income and rely on your insurance for your 
medical needs. The Plan denied your request. The Plan says your benefits for the comprehensive oral 
evaluation have been satisfied and the frequency limitation has been exceeded. The Plan says that these 
services were performed by a non-participating provider, and you are responsible for any difference between 
the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that 
you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure code every three years. The record shows that you received a 
comprehensive oral evaluation (D0150) on April 20, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The contract says that you cannot be billed more than the negotiated rate for 
covered services rendered by an in-network provider. You are responsible for the difference between the billed 
amount and allowed amount for the covered dental services because they were received OON. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and to pay more for 
the bitewing x-rays (D0272), and prophylaxis (D1110) provided on October 13, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), 
periapical x-ray (D0220), and filling (D2332) provided on September 15, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you should not have to 
pay anything. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered 
service. The Plan says that there is a 50% coinsurance for periapical x-ray that you receive out of network. The 
Plan also says there is a 55% coinsurance for filling that you receive out of network. 
 
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 limited oral evaluation is not 
among those covered under this benefit. Additionally, out of network providers may bill you for any amount 
greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to pay an 
additional amount for the limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2332) 
provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper left and upper 
right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says gingival irrigation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for the upper left and upper right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6058) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says the abutment supported crown is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested abutment supported 
crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve an abutment supported crown (D6058) for tooth # 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330), and a core buildup (D2950) 
provided by an out-of-network provider on September 14, 2021, to October 4, 2021. 
 
You asked the Plan to pay for endodontic therapy and a core buildup. You say that you needed these services 
because you were in extreme pain. The Plan denied your request. The Plan says the rendered dental 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 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 
endodontic therapy (D3330), and a core buildup (D2950) provided by an out-of-network provider on 
September 14, 2021, to October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on January 7, 2021. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you were informed that your dental 
coverage with the Plan should typically pay for this denture replacement. The Plan denied your request. The 
Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
maxillary partial denture (D5211) provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and two 
first intraoral periapical x-rays (D0220 x2) provided on October 19, 2021, and November 16, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-rays. 
You say that prior to receiving these services you were advised that you have a $1,000 allowance and an in-
network dentist would be paid in full up to that amount. You also say that you confirmed with the dentist that 
they were in-network. The Plan denied your request. The Plan says your benefits for these services have been 
satisfied and the frequency limitations have been exceeded. 
 
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, periodic oral exam and emergency 
diagnostic exam share a frequency limitation of two procedure codes per calendar year. The record shows that 
you received problem focused limited oral evaluations (D0140) on July 12, 2021, and October 19, 2021 and 
your periodic oral exam and emergency diagnostic exam benefit has been exhausted. The Plan contract also 
says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you 
received a first intraoral periapical x-ray (D0220) on July 12, 2021 and your intraoral x-rays benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140) and two first intraoral periapical x-rays (D0220 x2) provided on October 19, 2021, and 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) and bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve the endosteal implant and bone graft. You say that you had to have a tooth 
pulled and are now unable to chew. You also say that these services are needed so you can eat properly, and 
should be covered as medically necessary. The Plan denied your request. The Plan says these services are not 
included on 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 a 
surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement 
(D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat pouch (K0108). 
 
You asked the Plan to pre-approve a seat pouch. You say that you would like this claim reprocessed based on 
the medical documentation. The Plan denied your request. The Plan says this item does not serve a medical 
purpose as required by Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a seat pouch (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010), prefabricated abutment 
(D6056), and implant supported crown (D6066) for tooth # 10. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental implants and all related services are excluded from coverage. 
 
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 
implant placement (D6010), prefabricated abutment (D6056), and implant supported crown (D6066) for tooth # 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3310), post and core in addition to a 
crown (D2954), retainer crowns (D6750 x 4), and pontics (D6240 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you feel that these services should be 
covered. The Plan denied your request. The Plan says the root canal, post and core, retainer crowns, and pontics 
are not listed as covered services. 
 
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 root canal, post and core, retainer 
crowns, and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve a root canal (D3310), post and core in addition to a crown (D2954), retainer crowns 
(D6750 x 4), and pontics (D6240 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal provided on November 12, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were advised this provider was in network. 
You say that the service should be paid at 50% of the submitted amount. You also say that the closest in 
network provider is 68 miles away from you. The Plan denied your request. The Plan says the provider in this 
case is out of network. The Plan also says out of network providers may bill you for any amount greater than 
what the plan pays. 
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 and the root canal is listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays the provider. Therefore, 
we decided that the Plan does not have to pay for the root canal provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services provided on August 11, 2021, 
and September 8, 2021. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says they are reprocessing the claim for the 
buccal/labial frenectomy (D7961). The Plan says code D4277 is not covered under the Plan's supplemental 
dental benefit. As for dental code D0001, provided on August 11, 2021, you received this service prior to your 
dental coverage starting on September 1, 2021. 
 
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. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows that the Plan reprocessed the 
claim for the buccal/labial frenectomy (D7961). The file also shows that code D4277 is not covered under the 
Plan's supplemental dental benefit. As for dental code D0001, provided on August 11, 2021, you received this 
service prior to your dental coverage starting on September 1, 2021. Therefore, your total responsibility for 
these services is $1353. Therefore, we decided that the Plan does not have to pay additionally for the dental 
services provided on August 11, 2021, and September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 29, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you contacted the Plan to find a 
dentist in your area, and you never received any dental brochures for 2021, 2020, and maybe 2019. You also 
say that the representative you spoke with could have told you that if you went to a new dentist before the 3 
years, you would be responsible for the charges. The Plan denied your request. The Plan says 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) is limited to one procedure code every three years. The record shows that you received a 
comprehensive oral evaluation (D0150) on February 10, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on October 29, 2021.  
 
Your complaint about your unhappiness with how the Plan handled this issue and did not inform you of the 3-
year limitation for this service 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) HHA visits (CPT code G0156 x14). 
 
You asked the Plan to pre-approve the visits. You say that you have medical problems that you cannot handle 
by yourself. The Plan denied your request. The Plan says you are not receiving any concurrent physical 
therapy, skilled nursing care, occupational therapy, or speech therapy; therefore, you are not eligible for a home 
health aide. 
 
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 the visits. Our physician reviewer found 
the health plans denial should be upheld. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, associated HHA services are not shown to be medically necessary, 
reasonable or covered. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve fourteen (14) HHA visits (CPT code G0156 x14).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on October 1, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that your primary care provider sent you for 
this x-ray.  You said that you do not understand why the other service was denied, because you only received 
one service on this date. The Plan denied your request. The Plan says you were charged this copayment 
correctly and you do not owe anything for procedure code 99072 billed on the same date of service. 
 
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 $15 
copayment for basic radiological services.  
 
You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the basic radiological 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 that the Plan does not have to waive the copayment for x-ray services provided on 
October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says that the services are not covered. 
 
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 provided no documentation with the dental codes that are covered 
under each dental benefit description in the Plans contract. Without a list of dental codes that the Plan covers, 
we are unable to verify that the Plan's denial is correct. Therefore, we decided that the Plan has to pay for the 
dental services provided on November 10, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 7, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 7, 2021.