Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary care physician (PCP) office visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a PCP office visit. You say that you have seen this provider before and 
would like to continue to see this provider. The Plan denied your request. The Plan says the provider is an out-
of-network provider and there are multiple in-network providers that provide the same quality of care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a primary care physician (PCP) office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and to waive the 
copayment for periodontal maintenance (D4910) provided by a participating provider on November 15, 2021. 
 
You asked the Plan to pay for oral hygiene instructions (D1330) and to waive the copayment for oral hygiene 
instructions and periodontal maintenance. You say that you do not understand why this is not paid by the Plan. 
The Plan denied your request. The Plan says the coinsurance for D4910 has been correctly applied. The Plan 
says that D1330 is not a covered 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. You are being asked to pay a 70% coinsurance for the allowed amount 
for D4910. The total allowed amount is $94.The total amount you are being asked to pay $65.80 ($94 x 70% = 
$65.80). Therefore, we decided that the Plan does not have to pay for oral hygiene instructions (D1330) or 
waive the copayment for periodontal maintenance (D4910) provided by a participating provider on November 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (EKG) provided on June 10, 
2021, billed with code 93042. 
 
You asked the Plan to pay for the EKG as billed. You say that all services should be paid. The Plan denied your 
request. The Plan says 93042 requires a modifier when billed with 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 the rhythm electrocardiogram (EKG) provided on June 10, 2021, 
billed with code 93042.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) 
provided on October 30, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedures. You say that when you went to the 
dentist you were told that your dentures would be paid for. You also say that you do not have the money to pay 
for these services. The Plan denied your request. The Plan says this service is not covered by 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 two 
removable prosthodontic procedures (D5899 x2) provided on October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x7), alveoloplasty in 
conjunction with extractions (D7310), inhalation of nitrous oxide/analgesia (D9230), and drugs or 
medicaments dispensed in the office for home use (D9630 x7) provided on October 5, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the surgical extractions, alveoloplasty, inhalation of nitrous oxide/analgesia, and 
drugs or medicaments. You say that this claim is more surgical than dental, and you do have surgical coverage. 
You also say that you have paid the bill in full but feel that some compensation from the Plan is not too much 
to ask. The Plan denied your request. The Plan says the surgical extractions, alveoloplasty, and drugs or 
medicaments are not covered expenses under your dental plan. The Plan also says that services performed by 
an OON provider are not covered because your healthcare plan does not have OON 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. The contract also says that 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 
surgical extractions (D7210 x7), alveoloplasty in conjunction with extractions (D7310), inhalation of nitrous 
oxide/analgesia (D9230), and drugs or medicaments dispensed in the office for home use (D9630 x7) provided 
on October 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be rendered by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
dermatology services to be rendered by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is for stability and support purposes for the 
enrollee. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extraction procedures provided on October 12, 2021. 
 
You asked the Plan to pay for dental extractions. You say that the service at issue was a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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. Therefore, we decided that the Plan does not have to pay for dental extraction procedures 
provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided November 1, 2021. 
 
You asked the Plan to pay for the crown. You say that this service was necessary to replace a broken front 
tooth. 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 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 crown 
- porcelain/ceramic (D2740) provided November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that you did not have lab tests. The Plan denied 
your request. The Plan says a modifier was not billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The file shows that codes 87653, 87651, 87640, 87551, and 87474 were 
billed along with code 87801. We find that the codes at issue are not eligible for payment without an 
appropriate modifier billed on the claim. 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 
further pay for the lab services provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four alveoloplasties in conjunction with extractions 
(D7310 x4) provided on October 27, 2021. 
 
You asked the Plan to pay for the alveoloplasties. You say that the charge was part of the extraction which was 
covered under the Plan. You also say that they could not pull the teeth without doing the alveoloplasty which is 
why you believe it should be covered under the extraction coinsurance. The Plan denied your request. The Plan 
says this service is not covered. The Plan also says that the provider's office provided a pay agreement that the 
enrollee signed verifying that they agreed to be responsible for all services rendered on their behalf. 
 
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 four 
alveoloplasties in conjunction with extractions (D7310 x4) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921) provided 
November 19, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that this service was necessary for your health. 
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 
gingival irrigation  per quadrant (D4921) provided November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable unilateral partial denture (D5283). 
 
You asked the Plan to pre-approve the dental service. You say that you were advised by a plan representative 
that you needed to go to one of their providers. You say that you were informed the materials are too cheap and 
the denture would be of poor quality. You also say that now this code is being denied. The Plan denied your 
request. The Plan says removable unilateral partial denture 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removable unilateral 
partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removable unilateral partial denture (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310). 
 
You asked the Plan to pre-approve the consultation. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says this service is 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 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 
consultation (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), bitewings - four radiographic images (D0274) and panoramic radiographic image (D0330) 
provided September 20, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam, bitewing x-rays and panoramic x-rays. You say 
that these services were necessary, and you believed they would be covered. The Plan denied your request. The 
Plan says you have exceeded the frequency limits for these 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. The Plan covers the 
comprehensive oral exam and panoramic x-ray once every three plan years and bitewing x-rays once per plan year.   
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam, bitewing x-rays and panoramic x-ray were previously covered on June 24, 2021. Based on this 
information, we decided that the Plan's frequency limits for coverage of the comprehensive oral exam, bitewing 
x-rays and panoramic x-rays have been exceeded. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images 
(D0274) and panoramic radiographic image (D0330) provided September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 11, 2021. 
 
You asked the Plan to pay for the dental service. You say that you broke or cracked your tooth in November. 
You say that the emergency exam was to determine which tooth and procedure to be used. You also say that 
you feel this should be covered. The Plan denied your request. The Plan says 2 oral exams are covered per 
calendar year. The Plan also says that the frequency limit 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 and 2 oral exams are covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that 
you received on February 10, 2021, and August 18, 2021. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a detailed and extensive treatment planning (D9450) 
provided by a participating provider on November 4, 2021. 
 
You asked the Plan to pay for a detailed and extensive treatment planning. You say that you thought this was 
all covered because it was preventative care. The Plan denied your request. The Plan says D9450 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 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 a detailed 
and extensive treatment planning (D9450) provided by a participating provider on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an oral evaluation (D0140), periapical radiograph (D0220) and a crown 
restoration (D2740) provided by an out-of-network provider on January 7, 2021. 
 
You asked the Plan to pay for an oral evaluation, periapical radiograph, and a crown restoration. You say that 
that his tooth was broken, and he was at risk for an infection. The Plan denied your request. The Plan says that 
the services that were provided 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. The Plan covers an oral 
evaluation, periapical radiograph, and a crown restoration when the services are medically necessary and 
reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an oral evaluation, periapical radiograph, 
and a crown restoration. Our reviewer says that the documentation provided meets the criteria for coverage for 
an oral evaluation (D0140), radiograph (D0220) and crown restoration (D2740). Our physician reviewer found 
a review of the documentation indicates that a crown restoration for the tooth in question is medically 
reasonable and necessary to restore the tooth due to the amount of carious breakdown and fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of an oral evaluation, periapical radiograph, and a crown restoration have been 
met. Therefore, we decided that the Plan has to pay for an oral evaluation (D0140), periapical radiograph 
(D0220) and a crown restoration (D2740) provided an out-of-network provider on January 7, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vitoss Allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Vitoss in the setting of spinal fusion surgery have 
not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Vitoss allograft is experimental. More research is needed to show safety and efficacy when 
used as bone graft material. Iliac crest bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve Vitoss Allograft (CPT code 20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you have two very bad knees that a complete 
body x-ray showed that you are loaded with arthritis throughout your body. Not having a stair lift impacts your 
quality of life and stair climbing is extremely painful. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.