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

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on May 23, 2022, and the 
extraction of tooth #2 (D7140) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that this provider was recommended to you by your 
previous dentist. 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) provided on May 23, 2022, and the extraction of tooth #2 (D7140) provided on 
June 6, 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 April 25, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were advised that the Plan would pay 
for the dental services. The Plan denied your request. The Plan says the service at issue 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 limited 
oral evaluation (D0140) provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary to monitor the use of 
prescriptions. 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 laboratory services provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is necessary to monitor the use of 
prescriptions. 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 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is necessary to monitor the use of 
prescriptions. The Plan denied your request. The Plan says this code is not 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 services provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutmentsincludes placement 
(D6057 x 5) and the abutment supported porcelain fused to metal crowns (high noble metal) (D6059 x 5). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered 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 items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom 
fabricated abutmentsincludes placement (D6057 x 5) and the abutment supported porcelain fused to metal 
crowns (high noble metal) (D6059 x 5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom abutment (D6057) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not realize you had to use an in-network 
provider. 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 custom abutment (D6057) provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service January 26, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307 and 
G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this case, 
we have confirmed that code 83789 is a column II code to column I code 80307 and G0481. While code 83789 
was billed with modifier -59, the medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. 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 83789 billed for date of 
service January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not realize you had to use an in-network 
provider. 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 crown (D2740) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture repair provided from May 15, 2022, through May 17, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you did not know that you had to use an in-
network provider. 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 denture repair provided from May 15, 2022, through May 17, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay for more. 
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 periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided by an out-of-network provider on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteopathic manipulative treatment (98925 x 2) provided 
on April 7, 2022 and April 14, 2022. 
 
You asked the Plan to pay 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 these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the osteopathic manipulative treatment (98925 x 2) provided on April 7, 
2022 and April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 4, 2022. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you received notices that the provider was not in 
network. You say that you were advised services with this provider would be covered. You also say that these bills should be paid. The Plan denied your request. The Plan says the Tetanus vaccine is not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus 
vaccine. Therefore, we decided that the Plan does not have to pay for the services provided on May 4, 2022.  
 
Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adding a clasp to an existing partial denture on tooth 
#27 (D5660). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of 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 date of service March 11, 2022. 
Therefore, we decided that the Plan does not have to pre-approve adding a clasp to an existing partial denture 
on tooth #27 (D5660).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age, younger than 1 
year and older than 70 (List separately in addition to code for primary anesthesia procedure) (99100) provided 
March 23, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that please have the claims sent back for 
reprocessing. The Plan denied your request. The Plan says separate payment is never made for routinely 
bundled services and supplies. 
 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 the 
anesthesia services is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia for patient of extreme age, younger than 1 year and older than 70 (List 
separately in addition to code for primary anesthesia procedure) (99100) provided March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and antimicrobial agents (D4381) provided 
from February 25, 2022, through April 14, 2022, 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says your benefit for the crown has already been exhausted. The Plan says 
antimicrobial agents are 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, certain limitations apply. The record 
shows your benefit for the crown was exhausted on date of service March 28, 2022. Additionally, antimicrobial 
agents are not a covered benefit. Therefore, we decided that the Plan does not have to pay for a crown (D2740) 
and antimicrobial agents (D4381) provided from February 25, 2022, through April 14, 2022,
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory Pathogen Panel testing (0202U) provided on 
January 25, 2022. 
 
You asked the Plan to pay for the Respiratory Pathogen Panel testing. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0202U is a non-covered code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Respiratory pathogen Panel testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Respiratory Pathogen Panel testing (0202U) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on October 
14, 2021. 
 
You asked the Plan to pay for re-cement or re-bond crown. You say that the service was necessary and should 
be covered. The Plan denied your request. The Plan says the service at issue 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 re-cement 
or re-bond crown (D2920) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), bitewings 
(D0274), and intraoral imaging (D0220), provided by an out-of-network provider on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous in-network provider referred you 
to this new dentist. 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 comprehensive oral evaluation (D0150), bitewings (D0274), and intraoral imaging (D0220), 
provided by an out-of-network provider on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and intraoral imaging (D0210), provided by an out-of-network provider on May 6, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis, and intraoral imaging. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the enrollee does not 
have dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for a comprehensive oral evaluation 
(D0150), prophylaxis (D1110), and intraoral imaging (D0210), provided by an out-of-network provider on 
May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), 
intraoral periapical radiographic images (D0220, D0230), and bitewing radiographic images (D0274) provided 
on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never notified of change in the 
insurance. The Plan denied your request. The Plan says the services at issue are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for a periodic oral evaluation 
(D0120), teeth cleaning (D1110), intraoral periapical radiographic images (D0220, D0230), and bitewing 
radiographic images (D0274) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the approved knee already includes Stance Control. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The requested item 
exceeds your functional needs as you were already approved for the addition, endoskeletal knee-shin system, 
single axis, pneumatic swing, friction stance phase control (L5822) which has stance control. Our physician 
reviewer found that your condition does not meet criteria for coverage of these services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845).
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 April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. 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 April 28, 2022.