Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair of superficial wounds (12002, 12013) provided on 
June 18, 2021. 
 
You asked the Plan to pay for repair of superficial wounds. You say that you have provided records to support 
the services billed. The Plan denied your request. The Plan says rules for payment have not been met because 
the CPT codes at issue are inclusive to another billed code. 
 
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 codes 
12002 and 12013 are column II codes to column I code 27788. This claim has not been billed with appropriate 
modifiers 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 repair of superficial wounds (12002, 12013) 
provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging provided by an out-of-network provider 
on January 24, 2022. 
 
You asked the Plan to pay for panoramic imaging. You say that these x-rays were medically necessary. The 
Plan denied your request. The Plan says the benefit limit for the rendered services 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. The Plan covers one 
panoramic imaging every 60 months.  
 
We looked at the file, and Medicare rules. Evidence was provided to show that a panoramic radiographic image 
was provided on November 9, 2017. Based on this information, we decided that the Plan's rules for coverage of 
panoramic imaging have not been met. Therefore, we decided that the Plan does not have to pay for panoramic 
imaging provided by an out-of-network provider on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180), debridement of a peri-implant defect or defects surrounding a single implant, and 
surface cleaning of the exposed implant surfaces, including flap entry and closure (D6101), and surgical 
removal of implant body (D6100) provided September 14, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam, debridement and surgical removal of 
implant. You say that you would like these services 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 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 
comprehensive periodontal evaluation - new or established patient (D0180), debridement of a peri-implant 
defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including 
flap entry and closure (D6101), and surgical removal of implant body (D6100) provided September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported crown (D6058) provided on January 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that your plan covers crowns. You say that there is 
no disclaimer that a crown over an implant is not covered. You also say that your dentist is in network. The 
Plan denied your request. The Plan says the custom fabricated abutment and abutment supported crown are not 
listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment and 
abutment supported crown are not among those covered under this benefit. Additionally, the Schedule of 
Dental Benefits lists the specific dental services that are covered. Implant related services are not covered. 
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and 
abutment supported crown (D6058) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided by 
a network provider on February 2, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray (D0230). You say that you paid out-of-
pocket for the services and the codes are covered. You say you would like to be reimbursed. The Plan denied 
your request. The Plan says the claims were reprocessed at the in-network benefit level, however, only one 
intraoral x-ray is covered at 100% per calendar year. The second intraoral x-ray is 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 additional intraoral periapical x-ray 
(D0230) is not among those covered under this benefit. The Plan also has a maximum benefit of one intraoral 
x-ray per year. The requested service is not covered because the Plan paid for the initial intraoral periapical x-
ray on February 2, 2022, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the additional intraoral periapical x-ray (D0230) provided by a network provider on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) provided January 20, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you 
would like these services 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 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 
custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) provided January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that your teeth need to be removed 
and replaced with dentures. The Plan denied your request. The Plan says this service is not a covered benefit 
under Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial 
denture (D5226).  
 
Please Note: You have an individual dental policy with the Plan as well as a $550.00 reimbursement through 
the program. If you purchase the dentures, you may request reimbursement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing (81225, 81226) provided 
April 5, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on their medical condition. The Plan denied your request. The 
Plan says does not meet Medicare NCD/LCD criteria. Service is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Multiple outreach attempts were made to the providers office to 
verify if the provider wrote an order for the cardiovascular genetic testing without success. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the cardiovascular genetic testing (81225, 81226) provided 
April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), and endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided December 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the limited oral exam, periapical x-ray and root canal. You say that you feel you 
should be reimbursed 50% of the cost of the services. The Plan denied your request. The Plan says these 
services are not covered because they were provided OON. 
 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 the limited 
oral exam, periapical x-ray and root canal when rendered by a participating provider. 
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the limited oral exam, periapical x-ray and root canal have not been met. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation - problem focused (D0140), intraoral - periapical first 
radiographic image (D0220), and endodontic therapy, molar tooth (excluding final restoration) (D3330) 
provided December 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431), and a preventative 
service (D1999), provided by a participating provider on February 10, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test and a preventative service. You say that you 
were never told by the office that these services would not be covered. The Plan denied your request. The Plan 
says the rendered dental 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 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 an 
adjunctive pre-diagnostic test (D0431), and a preventative service (D1999), provided by a participating 
provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigations (D4921). 
 
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigations (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410), bone graft in conjunction with 
periradicular surgery (D3428), and retrograde filling (D3430). 
 
You asked the Plan to pre-approve an apicoectomy, bone graft, and retrograde filling. You say that you know 
that these services exceed the allowance, but you need them to be approved. The Plan denied your request. The 
Plan says these services are not covered under your 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 an 
apicoectomy (D3410), bone graft in conjunction with periradicular surgery (D3428), and retrograde filling 
(D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided February 1, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this was the first time you went to 
this dentist, and you were told the service would 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 Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on February 19, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided February 1, 2022.  
 
Your complaint about potentially being provided misinformation by a plan representative 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the titanium camber tube, carbon fiber TiShaft release 
bar and anodize color. 
 You asked the Plan to pre-approve the titanium camber tube, carbon fiber TiShaft release bar and anodize 
color. You say that these items are medically necessary. The Plan denied your request. The Plan says the 
criteria for coverage for these services have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves 
the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The anodize color 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. In addition, 
the titanium camber tube and carbon fiber TiShaft are available on the approved wheelchair and would not 
qualify for separate payment. Therefore, we decided that the Plan does not have to pre-approve the titanium 
camber tube, carbon fiber TiShaft release bar and anodize color.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removable appliance therapy (D8210), provided by an out-
of-network provider on November 8, 2021. 
 
You asked the Plan to pay for removable appliance therapy. You say that you would like the Plan to pay for 
this. You say that you were having a lot of jaw pain, and this helped. The Plan denied your request. The Plan 
says the rendered dental service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for removable appliance therapy (D8210), provided 
by an out-of-network provider on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental services. You say that you understand that implants are not 
covered. You say that every year your plan covers more items. You say that the market is heading into the 
direction of covering implants. You also say that at least a portion of the implants should be covered. The Plan 
denied your request. The Plan says dental implants 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 dental implants are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental x-ray (D0220), and a limited oral evaluation 
(D0140), provided by a participating provider. 
 
You asked the Plan to pay for a dental x-ray, and a limited oral evaluation. You say that this should be covered 
because of the extenuating circumstances. The Plan denied your request. The Plan says the benefit limit for the 
rendered dental services have already been met and 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 dental x-ray 
once every three years and one limited oral evaluation every six months. 
 
We looked at the file and Medicare rules. The benefit limit for D0220 and D0140 have already been met and 
exhausted. Based on this information, we decided that the Plan's rules for coverage of a dental x-ray, and a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a dental 
x-ray (D0220), and a limited oral evaluation (D0140), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367) and two reductions of osseous tuberosity (D7485 x2). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation and reductions of osseous 
tuberosity. You say that these services are necessary, and you would like them to be approved for coverage. 
The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
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 pre-approve a 
cone beam computed tomography (CT) capture and interpretation (D0367) and two reductions of osseous 
tuberosity (D7485 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on February 24, 2022. 
 
You asked the Plan to pay for the crown. You say that you were unaware that your dental coverage had 
changed and that there was no coverage for this service. The Plan denied your request. The Plan says this 
service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on February 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on February 24, 2021.
You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy services were being rendered. The incident-to requirements have not been met in this case. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on November 8, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder test provided to the enrollee on November 8, 2021.