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

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation - per site 
(D7953) provided on October 7, 2021. 
 
You asked the Plan to pay for bone replacement graft for ridge preservation - per site (D7953). You say that the 
bone replacement graft should be covered. The Plan denied your request. The Plan says bone replacement graft 
for ridge preservation - per site (D7953) is not a covered procedure. 
 
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 bone 
replacement graft for ridge preservation - per site (D7953) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), amalgam (D2140), bitewings (D0274), 
and a periodic oral evaluation (D0120), provided by an out-of-network provider on April 18, 2022, to April 21, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that this provider was out-of-
network. 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 prophylaxis (D1110), amalgam (D2140), bitewings (D0274), and a periodic oral evaluation (D0120), 
provided by an out-of-network provider on April 18, 2022, to April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recementing a crown on tooth #13 (D2920) provided on 
April 21, 2022. 
 
You asked the Plan to pay for recementing a crown. You say that you received inadequate information about 
the dental benefits. The Plan denied your request. The Plan says recementing a crown (D2920) is not covered 
by your dental 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 
recementing a crown on tooth #13 (D2920) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three placements of intra-socket biological dressings 
(D7922 x3) or pay more for the three extractions (D7210 x3) provided from March 12, 2022, to April 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the placements of intra-socket biological dressings and to pay more for the 
extractions. You say that you thought the treating provider was in-network. You also say that you cannot afford 
to pay this bill. The Plan denied your request. The Plan says placement of intra-socket biological dressing is not 
a covered benefit under your dental plan. The Plan also says the treating provider was OON, and your 
responsibility 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, placement of intra-socket biological 
dressing (D7922) is not among those covered under this benefit. You are also responsible for the difference 
between the billed amount and the allowed amount for covered dental services received OON. Therefore, we 
decided that the Plan does not have to pay for the three placements of intra-socket biological dressings (D7922 
x3) or pay more for the three extractions (D7210 x3) provided from March 12, 2022, to April 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the resin-based composite-one surface, 
posterior (D2391), resin-based composite-two surfaces, posterior (D2392), and the periodontal scaling and root 
planing-four or more teeth per quadrant (D4341 x 2) provided on May 20, 2022. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly to the services provided. 
 
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 20% 
coinsurance for comprehensive dental services, restorative services, endodontics, periodontics, and extractions.  
.   
 
You have been asked to pay $87.54 ($24.37+ $24.37 + $16.48 + $22.32) for the dental services provided. This 
includes the Plans allowed amount of $121.87 x 20% coinsurance=$24.37 x 2= $48.74 for the periodontal 
scaling and root planing services. This includes the Plans allowed amount of $82.44 x 20% coinsurance= 
$16.48 for the resin-based composite-one surface posterior. Additionally, this includes the Plans allowed 
amount of $111.60 x 20% coinsurance=$22.32 for the resin-based composite-two surfaces, posterior provided. 
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 the resin-based composite-one surface, posterior (D2391), 
resin-based composite-two surfaces, posterior (D2392), and the periodontal scaling and root planing-four or 
more teeth per quadrant (D4341 x 2) provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on April 13, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says no separate payment can be made for this 
code. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 22, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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 the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing services provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 15, 
2021. 
 
You asked the Plan to pay for an evaluation. You say that this service should be covered. The Plan denied your 
request. The Plan says this provider has opted out of Medicare and is not eligible for payment. 
 
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. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of an implant body for tooth 
number 4 (D6100). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual 
policy. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical 
removal of an implant body for tooth number 4 (D6100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
May 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider 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 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 dental 
services provided by an out-of-network provider on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330) provided by a participating 
provider on June 29, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that there should be more than just routine 
cleanings. The Plan denied your request. The Plan says the rendered dental work 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 pay for a resin-
based composite (D2330) provided by a participating provider on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 15, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 15, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274), 
periodic oral evaluation (D0120), intraoral-periapical first radiographic image (D0220), intraoral-periapical 
each additional radiographic image (D0230), and the dental cleaning (D1110) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the 
bitewing x-rays-four radiographic images (D0274), periodic oral evaluation (D0120), intraoral-periapical first 
radiographic image (D0220), intraoral-periapical each additional radiographic image (D0230), and the dental 
cleaning (D1110) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of impacted tooth (D7240) and therapeutic 
parenteral drug (D9610). 
 
You asked the Plan to pre-approve the removal of impacted tooth and therapeutic parenteral drug. You say that 
the enrollee needs upper teeth extractions. You also say that this surgery will require intravenous sedation due 
to the enrollee's history of seizures, as well as extreme anxiety. The Plan denied your request. The Plan says 
these services are not covered under the enrollee's benefit package. 
 
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 
removal of impacted tooth (D7240) and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 20, 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 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 the dental services on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the code cannot be 
separately reimbursed. 
 
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 the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. 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 testing services provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option and rear wheel performance spokes. 
 
You asked the Plan to pre-approve a transit option and rear wheel performance spokes. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 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 transit option 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. The rear wheel performance item at 
issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the 
general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the 
Plan does not have to pre-approve a transit option and rear wheel performance spokes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation post-operative office visit on July 19, 2022. 
 
You asked the Plan to pay for a re-evaluation post-operative office visit. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the 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 pay for a re-
evaluation post-operative office visit on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture - cast metal framework with 
resin denture bases (D5214) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration as you were 
misinformed about the enrollees policy and benefits. The Plan denied your request. The Plan says the 
enrollee's 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 the enrollee's benefit for the requested item or service was exhausted on date of service March 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture - cast metal 
framework with resin denture bases (D5214) provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system and enhanced steering 
perform unit, and medical necessities bag hooks. 
 
You asked the Plan to pre-approve a power seat elevation system and enhanced steering perform unit, and 
medical necessities bag hooks. You say that you disagree with the Plan's denial. The Plan denied your request. 
The Plan says the requested items are not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 
The rules also say that for equipment to be covered, it must primarily serve a medical purpose.   
 
We looked at the file and Medicare rules. The power seat elevation feature is not a covered benefit. The 
requested enhanced steering perform unit and medical necessities bag hooks do not serve a purpose that is 
primarily medical in nature. These items are available to the general public and would be helpful even to those 
who are not sick or injured. Based on this information, we decided that Medicare rules for coverage of a power 
seat elevation system and enhanced steering perform unit, and medical necessities bag hooks have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and 
enhanced steering perform unit, and medical necessities bag hooks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and does not have to 
pay for pulp caps on tooth #19 and 31 (D3120) and protective restorations on tooth #19 and 31 (D2940) 
provided on April 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider did not tell you that they were 
out-of-network. 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. The 
Plan also says that pulp caps (D3120) and protective restorations (D2940) are not covered by your dental 
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, pulp caps and protective restorations 
are not among those covered under this benefit. You have been asked to pay $205, which is the difference between the out-of-network providers charges and 
the Plans payment for a limited oral evaluation ($275 total billed amount - $70 Plans payment = $205). 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 limited oral evaluation (D0140) and does not have to pay for pulp 
caps on tooth #19 and 31 (D3120) and protective restorations on tooth #19 and 31 (D2940) provided on April 
1, 2022.