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

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation - new or established 
patient (D0150), panoramic film (D0330) and prophylaxis  adult (D1110) provided on June 23, 2022 and a 
resin-based composite - two surfaces, posterior (D2392) provided on June 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the dentist's office that 
you would not pay more than $110.00 for new patient services but the charges came to over $600.00. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation - new or 
established patient (D0150), panoramic film (D0330) and prophylaxis  adult (D1110) provided on 
June 23, 2022 and a resin-based composite - two surfaces, posterior (D2392) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown - porcelain fused to noble metal provided on 
March 3, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay for the service because 
the provider did not send a pre-authorization. The Plan denied your request. The Plan says the service is 
covered but limitations apply. 
 
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. Retainer crown - porcelain 
fused to noble metal  one procedure code every five calendar years. 
 
We looked at the file, the Plans rules, and Medicares rules. You received two retainer crown - porcelain fused 
to noble metal on March 3, 2022. You are only allowed one covered retainer crown - porcelain fused to noble 
metal every five calendar years. Therefore, we decided that the Plan does not have to pay for one retainer 
crown - porcelain fused to noble metal provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36140 billed for date of service February 17, 
2022. 
 
You asked the Plan to pay for procedure code 36140. You say that the records should be reviewed. The Plan 
denied your request. The Plan says payment for code 36140 is bundled into payment for code 36905. 
 
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 36140 
is a column II code to column I code 36905. 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 procedure code 36140 billed for date of service February 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and first periapical x-ray 
(D0220) provided on July 20, 2022. 
 
You asked the Plan to pay for the limited oral exam and first periapical x-ray. You say that you expected these 
services to be covered. The Plan denied your request. The Plan says these services are not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
limited oral exam (D0140) and first periapical x-ray (D0220) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
July 20, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service February 4, 2020. Specifically, 
the Plan contract says that one panoramic radiographic image is covered every three years. You previously 
received a panoramic radiographic image on February 4, 2020, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay 
for the panoramic radiographic image (D0330) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the extraction 
(D7210) provided on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the extraction should be covered under medical 
since it was performed by an oral surgeon. The Plan denied your request. The Plan says your benefit for the 
limited oral evaluation (D0140) and the extraction (D7210) 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service July 20, 2022. Also, the 
record shows that you reached your $2,000 has been met. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) and the extraction (D7210) provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) Tooth #4, 7, 10, 13, 20, 25 and 29. 
 
You asked the Plan to pre-approve dental services. You say that your implant is not a covered benefit, but you 
would like the Plan to cover it. The Plan denied your request. The Plan says this service is 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 Plans coverage rules apply in this case. Surgical placement of implant 
body: endosteal implant (D6010) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Surgical placement of 
implant body: endosteal implant (D6010) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010) 
Tooth #4, 7, 10, 13, 20, 25 and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for dental services provided on June 16, 2022. 
 
You asked the Plan to reimburse for the dental services. You say that you want the Plan to reimburse you, 
$1400 for dental services provided on June 16, 2022. The Plan denied your request. The Plan says your benefit 
for the requested item or service has 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit was exhausted on date of service June 9, 2022, and June 16, 2022. The Plan paid $280 on 
June 9, 2022, and $1,220 on June 16, 2022 ($280 + $1,220 = $1,500/maximum allowed). You are responsible 
for the remaining $1,400 for services on June 16, 2022. Therefore, we decided that the Plan does not have to 
reimburse for dental services provided on June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital chemotherapy visits 
provided from February 25, 2021, to March 9, 2022. 
 
  You asked the Plan to waive the copayment for outpatient hospital chemotherapy visits. You say that you are 
submitting an appeal to dispute the $200 copayments that applied to your outpatient hospital chemotherapy 
treatments for dates of service from February 25, 2021, to March 9, 2022. You say that you were not aware you 
had a $200 copayment each visit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $200 
copayment per day for each Medicare-covered outpatient hospital service.  
 
You have been asked to pay a $1,200 copayment for outpatient hospital chemotherapy visits ($200 per visit x 6 
visits = $1,200). This item/service falls within the Outpatient Hospital 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 outpatient hospital chemotherapy visits provided from February 25, 
2021, to March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant body: endosteal implant 
tooth # 4 (D6010) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that when you called you were told that the service 
was covered. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a surgical placement of implant body: endosteal implant tooth # 4 (D6010) provided on May 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown porcelain (D2740) and core buildup (D2950) Tooth 
#14 provided on March 31, 2022. 
 
You asked the Plan to pay for dental services. You say that you were denied coverage for crowns even though 
you have the rider. The Plan denied your request. The Plan says the cost share 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 Plans coverage rules apply in this case. This benefit includes crown 
porcelain and core buildup. You pay 50% coinsurance for Class 3 Major Services. 
 
  We looked at the file, the Plans rules, and Medicares rules. Crown porcelain (D2740) was paid at the less 
expensive procedure crown metal (D2751) for tooth #14. The allowed amount is $958 x 50% coinsurance = 
$479 enrollee responsibility.  Therefore, we decided that the Plan does not have to pay for crown porcelain 
(D2740) and core buildup (D2950) Tooth #14 provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for endodontic therapy (D3330) provided by 
an out-of-network provider on June 20, 2022. 
 
You asked the Plan to waive the coinsurance for endodontic therapy. You say that you disagree with these 
charges. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 50% 
coinsurance for root canals (endodontic services).  
 
You have been asked to pay a 50% coinsurance of the allowed amount for endodontic therapy. This 
item/service falls within the root canals (endodontic 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 coinsurance for endodontic therapy (D3330) provided by an out-of-network provider on June 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis rendered on April 29, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 20610 was related to and billed 
within 90 days of major procedure 29880 billed on March 10, 2022. Payment for code 20610 is included in the 
global surgical package. Therefore, we decided that the Plan does not have to pay for the arthrocentesis 
rendered on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 10, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at
a lower level of care such as skilled nursing facility (SNF), home health or outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), two gingival 
irrigations (D4921 x2), removable prosthodontic procedure (D5899), and two drugs or medicaments dispensed 
in the office for home use (D9630 x2), or pay more for the two periodontal scalings and root planings (D4342 
x2), complete maxillary denture (D5110), and mandibular partial denture (D5226) provided from April 12, 
2022, to August 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, gingival irrigations, removable prosthodontic 
procedure, and drugs or medicaments, and to pay more for the scalings and planings, complete maxillary 
denture, and mandibular partial denture. You say that you were told that the office you went to accepted your 
insurance, but were later informed that the dentist was not in-network. The Plan denied your request. The Plan 
says the adjunctive pre-diagnostic test, gingival irrigations, removable prosthodontic procedure, and drugs or 
medicaments are not covered expenses under your dental plan. The Plan also says that because these services 
were performed by a non-participating provider, you are responsible for any difference between the Maximum 
Allowable Fee and the amount the provider bills you for the 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 adjunctive pre-diagnostic test 
(D0431), gingival irrigation (D4921), unspecified removable prosthodontic procedure (D5899), and drugs or 
medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. The 
contract also clearly states that you are responsible for a $25 copayment for each scaling and root planing, and 
a 50% coinsurance for each complete denture and partial denture, plus the difference between the billed 
amounts and allowed amounts because these were covered services received OON. Therefore, we decided that 
the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), two gingival irrigations (D4921 
x2), removable prosthodontic procedure (D5899), and two drugs or medicaments dispensed in the office for 
home use (D9630 x2), or pay more for the two periodontal scalings and root planings (D4342 x2), complete 
maxillary denture (D5110), and mandibular partial denture (D5226) provided from April 12, 2022, to August 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve local anesthesia (D9210) and gingival irrigation 
(D4921). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the requested procedures do not appear in the comprehensive list of covered 
dental procedures and are therefore not covered. 
 
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 local 
anesthesia (D9210) and gingival irrigation (D4921).