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

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), a crown (D6065), and 
sinus augmentation (D7952) for tooth #3 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied services. The 
Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
endosteal implants, crowns, and sinus augmentation are not covered by the 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 an 
endosteal implant (D6010), a crown (D6065), and sinus augmentation (D7952) for tooth #3 and #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a post operative office visit (D0171) provided on June 24, 
2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says a post operative 
office visit (D0171) is not covered by your routine 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 a post 
operative office visit (D0171) provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D2394). 
 
You asked the Plan to pre-approve the dental services (D2394, D5821 and D5226). You say that you would 
like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
dental services (D5821 and D5226) are approved, while dental service (D2394) is being denied. 
 
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 the 
dental service (D2394).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the harvesting of bone for a graft procedure for teeth #3, 
#11, and #13 (D7295). 
 
You asked the Plan to pre-approve dental services. You say that the procedure should be covered. The Plan 
denied your request. The Plan says the claim was processed correctly. The service you requested is not a 
covered benefit. The contract clearly states that any dental services not listed in the table of covered services 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
harvesting of bone for a graft procedure for teeth #3, #11, and #13 (D7295).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a anesthesia sedation and tooth extraction services (D7210, 
D9222, D9223) provided on May 17, 2022. 
 
You asked the Plan to pay for the anesthesia sedation and tooth extraction services. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within 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 a 
anesthesia sedation and tooth extraction services (D7210, D9222, D9223) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3911, D3331) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve a 
root canal (D3911, D3331)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy of a molar tooth (D3330), treatment of a 
root canal obstruction (D3331), pulp vitality tests (D0460), and a limited problem-focused oral evaluation 
(D0140) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression that your 
insurance would cover the procedures you needed to fix your dental issues. You say you are on disability and 
cannot afford to pay the bill. You asked the Plan to pay the bill as an exception. The Plan denied your request. 
The Plan says the claim was processed correctly. The Plan says the record indicates that you did not contact the 
Plan prior to the date of service to verify your benefits. Even though the oral exam is a covered service, you 
had already exhausted your benefit at the time of service. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the oral evaluation was exhausted on date of service May 3, 2022. The remaining 
requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for endodontic therapy of a molar tooth (D3330), treatment of a root canal obstruction 
(D3331), pulp vitality tests (D0460), and a limited problem-focused oral evaluation (D0140) provided on May 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), and cone beam imaging (D0364) provided on May 19, 2022, and does not have to waive the cost 
share for a resin-based composite filling (D2392) provided on May 24, 2022. You asked the Plan to pay for an evaluation and imaging and to waive the cost share for a filling. You say that 
you disagree with the processing of these claims. The Plan denied your request. The Plan says dental services 
are not covered when received by an out-of-network provider. The Plan also says that you have been charged 
the correct cost sharing amount for a filling. 
 
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 there is a $50 
deductible for basic and major dental services. The contract also says that the enrollee must pay 20% 
coinsurance after the deductible is met for a filling. 
 
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 a limited oral evaluation, a periapical x-ray, and cone beam imaging from an 
out-of-network provider on May 19, 2022. Though the Plan offers a dental benefit in excess of Medicare 
coverage, these items and services are not covered under this benefit when received from an out-of-network 
provider. 
 
You have a $50 deductible which applies to a filling, and the deductible was not met at the time the services 
were received on May 24, 2022. The allowed amount for the filling after the deductible was satisfied is $46 
($96 original allowed amount - $50 deductible = $46 remaining allowed amount). You have been asked to pay 
$9.20, which is 20% coinsurance of the remaining allowed amount for a filling ($46 remaining allowed amount 
x 20% coinsurance = $9.20). You have been asked to pay a total of $59.20 for a filling ($50 deductible + $9.20 
coinsurance = $59.20). This item/service falls within the dental 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 pay for a limited oral evaluation (D0140), a periapical x-ray (D0220), and cone beam imaging 
(D0364) provided on May 19, 2022, and does not have to waive the cost share for a resin-based composite 
filling (D2392) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D6245). 
 
You asked the Plan to pre-approve the dental services (D6750 and D6245). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the members 
2022 Evidence of Coverage does not contain verbiage stating retainer crowns (D6750) are not covered and the 
plan is overturning service code D6750. However, the requested service (D6245) pontic-porcelain/ceramic 
crown is 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 the 
dental service (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push handle for a manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a push handle for a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sedation (D9243 and D9239). 
 
You asked the Plan to pre-approve the dental services. You say that the dental service is necessary because you 
are in pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because sedation not covered by the 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 the 
sedation (D9243 and D9239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022, to June 22, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022, to June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for plaque removal, a periodic oral 
evaluation, and pre-diagnostic mucosal test (D0120, D1110, D0431) provided on June 22, 2022. 
 
You asked the Plan to waive the cost-sharing for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says procedural code D0431 
denied correctly as it does not fall within your dental benefits and the cost-sharing for codes: D0120, D1110 are 
correct, cost sharing is a contractual obligation under the plan and cannot be waived. 
 
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 waive the cost-
sharing for plaque removal, a periodic oral evaluation, and pre-diagnostic mucosal test (D0120, D1110, D0431) 
provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental services. You say that upon examination, the enrollee was found 
to have bilateral mandibular tori which will need to be reduced in order for a proper fitting denture to be 
completed. 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 you are requesting two (2) removal of torus mandibularis procedures. One procedure has been approved.  
The benefit for the requested item or service is exhausted as the EOC confirms you are allowed one procedure 
per calendar year. Therefore, we decided that the Plan does not have to pre-approve removal of torus 
mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9612). 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for you to receive 
this dental service. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because therapeutic parenteral drugs are not covered by the 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 
therapeutic parenteral drug (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied authorization. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the claim was processed correctly. According to the Plan contract, the 
requested services 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 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 
complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture (D5110 and D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need a replacement and would like to 
appeal the denied dental services. 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 the date of service of July 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture (D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 8, 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 February 20, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a soft tissue graft procedure and materials to aid in soft and 
osseous tissue regeneration (D4265, D4277) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 a soft 
tissue graft procedure and materials to aid in soft and osseous tissue regeneration (D4265, D4277) provided on 
June 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (J8499) provided from April 1, 
2022, through April 5, 2022.   
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(J8499) provided from April 1, 2022, through April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for electromyography studies (51785, 95861) provided on November 11, 2021.

You asked the Plan to pay for the electromyography studies. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of codes 51785, & 95861 are needle electromyography studies.

We find that CPT code 51785, & 95861 is not supported in the medical record. Specifically, the provided procedure report does not document the procedures billed. Based on this information, we decided that Medicare rules for coverage of the electromyography studies have not been met. Therefore, we decided that the Plan does not have to pay for electromyography studies (51785, 95861) provided on November 11, 2021.