Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for treatment with Prolia (J0897) provided on 
April 13, 2021. 
 
You asked the Plan to waive the coinsurance for Prolia. You say that authorization for coverage of the service 
at issue was received from the Plan. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for drugs covered under Medicare Part B.  
 
You have been asked to pay $241.08, or 20% of the Medicare-allowed charge of $1,205.40, for Prolia. Prolia 
falls within the "Medicare Part B prescription drugs" 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 coinsurance for treatment with Prolia (J0897) provided on April 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second of two units of an ultrasound scan of extremity 
veins (93971x1) billed for date of service August 6, 2021. 
 
You asked the Plan to pay for a second ultrasound scan of extremity veins. You say that you have provided 
medical records to substantiate the service at issue. The Plan denied your request. The Plan says rules for 
payment have not been met because the provided records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code.  
We find that 2 units of CPT code 93971 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 93971. Based on this information, we decided that Medicare rules for coverage of 
a second ultrasound scan of extremity veins have not been met. Therefore, we decided that the Plan does not 
have to pay for the second of two units of an ultrasound scan of extremity veins (93971x1) billed for date of 
service August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
December 3, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you feel you should not have 
to pay anything for this service. 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 
complete series of intraoral x-rays (D0210) provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110) 
and complete lower denture (D5120) provided on January 26, 2021, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental items. You say that you were assured by the 
dentist office that this was going to be covered and not to worry. You say that the next day after receiving your 
teeth, you were informed you owed them $1,100. You also say that you are unable to afford this amount. The 
Plan denied your request. The Plan says the claim was denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out of network providers have not 
agreed to provide services at contracted fees. You are responsible 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 
complete upper denture (D5110) and complete lower denture (D5120) provided on January 26, 2021, by the 
out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device (D7880), provided on October 13, 2021. 
 
You asked the Plan to pay for the occlusal orthotic device. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not 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 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 
occlusal orthotic device (D7880), provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230) provided on October 
26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you woke up with a bad toothache. You say that 
a plan representative gave you the name of a dentist to go to. You say that you saw a lady dentist. You say that 
your denial lists a male dentist. You also say that you should not have to pay this bill. The Plan denied your 
request. The Plan says periapical x-rays are not covered 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 periapical x-rays are not among 
those covered under this benefit. The record shows that you were not enrolled in the optional supplemental 
dental rider on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 
periapical x-rays (D0220, D0230) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair resin partial denture base, maxillary (D5612) 
provided December 1, 2021. 
 
You asked the Plan to pay for the upper partial denture repair. You say that you cannot afford the cost of the 
service at this time. 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 repair 
resin partial denture base, maxillary (D5612) provided December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided June 22, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you didn't realize the same code was 
previously submitted to the Plan. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for this 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. The Plan covers the limited 
oral exam once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on May 5, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation - problem focused (D0140) provided June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on September 7, 2021, 
reported with code 38720. 
 
You asked the Plan to pay for the services as billed. You say that the records clearly support the reporting of 
code 38720. The Plan denied your request. The Plan says these services are not supported 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 38720 is Cervical lymphadenectomy (complete). 
We asked our coder 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 the services as billed. Our reviewer says that the 
documentation does not support the use of this code. Our reviewer found the operative report does not confirm 
a complete lymphadenectomy including blood vessels, nerve, and muscles. The report describes several lymph 
nodes and fat. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on September 7, 2021, reported with code 38720.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), and 
fluoride varnish (D1206) provided on May 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that in the past, your plan has always paid for dental 
services. You say that now your plan is saying that you were overpaid. You also say that you feel it was the plans mistake and that you cannot afford this bill. The Plan denied your request. The Plan says the provider in 
this case has opted out of Medicare. The Plan also says that payment cannot be made to a provider that has 
opted out of Medicare. 
 
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, dental services received by a provider 
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), and fluoride varnish (D1206) 
provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), and fluoride varnish (D1206) provided on November 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for over 10 
years. You say that this is the first time you have received a bill. You also say that you cannot afford this bill. 
The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also 
says that services performed by a provider that has opted out of Medicare are not payable. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), 
and fluoride varnish (D1206) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a soft tissue graft provided by an out-of-network provider on 
November 16, 2021. 
 
You asked the Plan to pay for a soft tissue graft. You say that this surgery was medically necessary. The Plan 
denied your request. The Plan says the services that were provided are 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 soft 
tissue graft provided by an out-of-network provider on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue, soft, (D7286) provided 
on October 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that when you made your appointment, you were not 
advised that the provider did not participate with Medicare. You also say that you were not made aware of this 
until after you received the service. The Plan denied your request. The Plan says services performed by a 
provider that has opted out of Medicare are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Additionally, the services at issue in this appeal were provided in a non-urgent, non-emergent 
situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does 
not have to pay for the incisional biopsy of oral tissue, soft, (D7286) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on November 15, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that at no 
time were you informed that you had maximized your benefits for your routine cleaning and exam. You also 
say that you had no idea a routine cleaning and bitewings were part of the annual maximum since the book says 
$0. The Plan denied your request. The Plan says your benefit has been exhausted. 
 
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 Plan offers a $1,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on February 10, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), 
and prophylaxis (D1110) provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on May 13, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that these services were 
medically necessary and should be paid. The Plan denied your request. The Plan says 83789 cannot be paid as 
it is included in payment for the drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  
We looked at the file and Medicare rules. We find that code 83789 is used to represent specimen validity 
testing which is not separately paid. Based on this information, we decided that Medicare rules for coverage of 
the unspecified mass spectrometry testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the unspecified mass spectrometry provided along with drug testing on May 13, 2021, billed with 
code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), and intraoral - complete series of radiographic images (D0210) provided 
November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam, dental cleaning and complete series of x-rays. You say 
that you have always used this dentist and have never been refused coverage in the past. The Plan denied your 
request. The Plan says these services are not covered when provided OON.  
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 periodic 
oral exam, dental cleaning and complete series of x-rays when the services are provided by a network provider.  
 
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 periodic oral exam, dental cleaning and complete series of x-rays have not been met. Therefore, we decided 
that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - 
adult (D1110), and intraoral - complete series of radiographic images (D0210) provided November 16, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and extraction (D7140) 
provided from June 22, 2021, to July 13, 2021. 
You asked the Plan to pay for the dental services. You say that you live in a rural area with limited access to 
dentists. You say that no one informed you that you needed to see an oral surgeon to have your tooth extracted. 
You also say that you are on a very limited income. The Plan denied your request. The Plan says dental 
services performed by a provider that has opted out of Medicare 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) and extraction (D7140) provided 
from June 22, 2021, to July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a foreign provider on October 4, 2021. 
 
You asked the Plan to pay for dental services. You say that it was a lot less expensive to get these services 
provided outside of the United States. The Plan denied your request. The Plan says these services could have 
been provided within the United States. 
 
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 dental 
services provided by a foreign provider on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rebase complete upper denture (D5710) provided on 
September 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that there is a hole in the roof of the denture. You say 
that food was getting into the hole and preventing the denture from staying in place. You also say that it is not 
good for your mouth to have teeth moving around when you are eating. The Plan denied your request. The Plan 
says rebase complete upper denture is not listed as a covered dental 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 rebase complete upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
rebase complete upper denture (D5710) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9945) provided on November 18, 2021. 
 
You asked the Plan to pay for the dental item. You say that your dentist advised you need an occlusal guard to 
prevent further damage to your teeth. You also say that you dentist advised this is an extreme case. The Plan 
denied your request. The Plan says occlusal guard is not a covered dental item. 
 
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 occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard 
(D9945) provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit. 
 
You asked the Plan to pre-approve a tie down kit. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a tie down kit is for use in transportation and not for home 
use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a tie down kit.