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

 
We decided that the Plan does not have to pay for the re-cement or re-bond fixed partial denture (D6930) 
provided on November 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that this is a basic service. You also say that you paid 
$25 per month in 2021 for the enhanced coverage and it was a total waste of money. The Plan denied your 
request. The Plan says that the claim denied correctly. 
 
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 re-cement or re-bond fixed partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the re-cement or re-bond fixed partial denture (D6930) provided on November 29, 2021.  
 
Your complaint about your enhanced dental coverage being a waste of money 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided by an out-of-network 
provider on December 8, 2021. 
 
You asked the Plan to pay for a consultation. You say that you do not agree with these charges. The Plan 
denied your request. The Plan says this appeal has been correctly denied. 
 
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 
consultation (D9310) provided by an out-of-network provider on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
images (D0210) provided by a participating provider on December 7, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral images. You say that you were in a 
lot of pain and needed to get your tooth looked at. The Plan denied your request. The Plan says the benefit limit 
for these services have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and intraoral images once every three years.  
 
 We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0210 were 
previously provided on September 14, 2021. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and intraoral images have not been met. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral images (D0210) 
provided by a participating provider on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and four 
gingival irrigations (D4921 x4) provided on November 18, 2021. 
 
You asked the Plan to pay for the topical application of fluoride varnish and gingival irrigations. You say that 
you had periodontal disease where you had to have these services done. The Plan denied your request. The Plan 
says these services are not covered under your 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 
topical application of fluoride varnish (D1206) and four gingival irrigations (D4921 x4) provided on November 
18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for the periodic oral evaluation and prophylaxis. You say that you 
were unaware that you had a dental copay for each service you received. You also say that none of the 
documents sent to you advised you of a copay for dental services. The Plan denied your request. The Plan says 
the copayment amount you are being charged was applied 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, you are responsible for a $15 
copayment per service for this visit. Therefore, we decided that the Plan does not have to waive the copayment 
for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional extractions, erupted tooth requiring removal of 
bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
December 1, 2021. 
 
You asked the Plan to pay for the additional extractions. You say that these extractions were necessary, and 
you feel they should be covered. 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 two 
extractions per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that two tooth extractions were covered on the same date of service. Based on this information, we decided that the Plan's rules for 
coverage of the additional extractions have not been met. Therefore, we decided that the Plan does not have to 
pay for the additional extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210) provided December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable back post with push handles (K0108). 
 
You asked the Plan to pre-approve an adjustable back post with push handles. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not needed. 
 
The Plan must follow Medicare rules. Medicare rules say that a complete manual wheelchair base includes a 
sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame 
structured in such a way as to be capable of accepting a back system. 
 
We looked at the file and Medicare rules. A seat back is included in the wheelchair base and cannot be 
separately approved. Based on this information, we decided that Medicare rules for coverage of an adjustable 
back post with push handles have not been met. Therefore, we decided that the Plan does not have to pre-
approve an adjustable back post with push handles (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 endosteal implants (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says dental implants 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental implants are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 8 
endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 25, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this procedure was required by 
your dentist because you were considered a new patient even though you were a prior patient there in 2017. 
You also say that your plan is supposed to cover 2 exams per year, and you feel that this evaluation should 
count as 1 of them. The Plan denied your request. The Plan says benefits have been provided previously for a 
similar service within the time period. 
 
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, comprehensive oral evaluations 
(D0150) are limited to 1 per lifetime, per dentist. The record shows that you received a comprehensive oral 
evaluation (D0150) on March 17, 2016 by same treating facility as you received the comprehensive oral 
evaluation (D0150) at appeal, 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 January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on 
April 8, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that this service should be covered. 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the periodontal maintenance (D4910) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit for a power wheelchair. 
 
You asked the Plan to pre-approve transit kit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this component is correct, because a transit 
kit is not primarily medical in nature. 
 
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 transit kit for a power wheelchair.
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 on December 
8, 2021. 
 
You asked the Plan to pay for dental services. You say that this provider is not on the opt-out list. 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 October 1, 2022. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and problem focused limited oral evaluation (D0140) provided on January 14, 2022. 
 
You asked the Plan to pay for the core buildup and problem focused limited oral evaluation. You say that you 
do not want these services to be denied. The Plan denied your request. The Plan says core buildup is not 
covered under your plan. The Plan also says that the problem focused limited oral evaluation exceeds the 
maximum allowed per period for the procedure grouping. 
 
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, core buildup, including any pins when 
required (D2950) is not among those covered under this benefit. The contract says that you are limited to 1 oral 
exam every 6 months. The record shows that you received a comprehensive oral evaluation (D0150) on August 
10, 2021 and your oral exams benefit had been exhausted for the period. Therefore, we decided that the Plan 
does not have to pay for the core buildup, including any pins when required (D2950) and problem focused 
limited oral evaluation (D0140) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral evaluation (D0150), panoramic 
x-ray (D0330), fillings (D2392, D2391), and cleaning (D1110) provided from December 14, 2021, to 
December 16, 2021 by the out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you confirmed the 
services would be covered at 100%. You say that the office staff confirmed this too. You also say that you 
would not have had these services done if you had known the dentist was out of network. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 and the services are listed as covered, 
there is a 50% coinsurance for covered dental services that you receive out of network. The record does not 
include call details prior to the date of service regarding the provider's network status. 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 oral evaluation (D0150), panoramic x-
ray (D0330), fillings (D2392, D2391), and cleaning (D1110) provided from December 14, 2021, to December 
16, 2021 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not choose the doctor 
you went to and believe he ordered some things that were unnecessary. You also say that all you wanted was to 
have your teeth checked and cleaned. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on February 20, 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 January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided February 3, 2022. 
 
You asked the Plan to pay for the additional periapical x-rays. You say that the first dentist did not have a 
hygienist to perform a cleaning. 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 Plan's coverage rules apply in this case. The Plan covers periapical x-rays once per calendar year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the additional periapical x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement 
graft for ridge preservation (D7953), surgical extraction (D7210), and intravenous moderate (conscious) 
sedation/analgesia (D9239) provided on January 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft, surgical extraction, and 
intravenous moderate (conscious) sedation/analgesia. You say that the tooth in front of your bridge broke off at 
the gum line and you were in agonizing pain. The Plan denied your request. The Plan says guided tissue 
regeneration and bone replacement graft 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration (D4266) 
and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The 
contract clearly states 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 guided tissue regeneration (D4266), 
bone replacement graft for ridge preservation (D7953), surgical extraction (D7210), and intravenous moderate 
(conscious) sedation/analgesia (D9239) provided on January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 10, 2021. 
 You asked the Plan to pay for the lab services. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on February 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 28, 2022. 
 
You asked the Plan to pre-approve SNF care after May 28, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after May 28, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found continued daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after May 28, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after May 28, 2022.