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

 
We decided that the Plan does not have to pay for an oral evaluation (D0150), a cleaning (D1110), and x-rays 
(D0330) provided an out-of-network (OON) provider on May 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was an OON 
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 an oral evaluation (D0150), a cleaning (D1110), and x-rays (D0330) provided an out-of-network 
(OON) provider on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial lower denture (D5821). 
 
You asked the Plan to pre-approve an interim partial lower denture. You say that without the tooth, you are 
noticing a difference in your speech. You also say it has affected your appearance. The Plan denied your 
request. The Plan says the requested item is 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 
interim partial lower denture (D5821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implants (D6056, D6066, and D6096) provided on 
May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought that the dental services you 
received would be covered by the Plan. The Plan denied your request. The Plan says the denial of payment was 
correct, because dental implants 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 pay for the dental 
implants (D6056, D6066, and D6096) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and a panoramic x-ray (D0330) provided on February 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have $2,000 in dental coverage. The Plan 
denied your request. The Plan says the dental services were received from a non-participating 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 a non-participating 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 a non-participating provider. Therefore, we decided that the Plan does 
not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and a panoramic x-ray (D0330) 
provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for restorative procedures (D2999), guided 
tissue regeneration on tooth #5 and 18 (D4266), the removal of a benign cyst on tooth #5 (D7460), extractions of tooth #5 and 18 (D7210), and bone replacement grafts on tooth #5 and 18 (D7953) provided on March 22, 
2022, and gingival flap procedures (D4240 x 4) and chlorhexidine provided on March 29, 2022. 
 
You asked the Plan to reduce the cost share for the dental services. You say that you were overcharged for 
these services. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount for the gingival flap procedures and the extractions. The Plan also says that any services not listed in 
the Dental Rider are not covered. 
 
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 $300 
copayment for each gingival flap procedure (D4240). The contract also says that you must pay a $65 
copayment for each extraction (D7210). 
 
You have been asked to pay a $65 copayment for each extraction on March 22, 2022. You have also been 
asked to pay a $300 copayment for each gingival flap procedure on March 29, 2022. The requested dental 
services fall 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.  
 
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, restorative procedures (D2999), guided 
tissue regeneration (D4266), removal of benign cysts (D7460), bone replacement grafts (D7953), and 
chlorhexidine are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to reduce the cost share for restorative procedures (D2999), guided tissue regeneration on tooth #5 and 18 
(D4266), the removal of a benign cyst on tooth #5 (D7460), extractions of tooth #5 and 18 (D7210), and bone 
replacement grafts on tooth #5 and 18 (D7953) provided on March 22, 2022, and gingival flap procedures 
(D4240 x 4) and chlorhexidine provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the SNF stay, wheelchair and leg rests 
provided from March 1, 2022, through April 21, 2022. 
 
  You asked the Plan to waive the cost share for the SNF stay, wheelchair and leg rests. You say that you were 
not notified of when the services were provided, and you do not recognize the providers. You say that the 
charges should be verified to reflect your insured obligation. The Plan denied your request. The Plan says the 
cost for the out-of-network physician services has been removed. The Plan also says the cost for the SNF stay 
and durable medical equipment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network, Medicare-covered durable medical equipment item and $178 per day, for 
days 21-100 for each in-network, Medicare-covered SNF stay.  
 
You have been asked to pay a total of $729.12 for the SNF stay, wheelchair, and leg rests.  
 
Date of Service Service Cost Per Contract Member Liability 
March 1, 2021- 
March 21, 2021 
SNF Stay $178/ day, for days 21-
100 
$712 
March 21, 2021 Wheelchair 20% $6.08 
March 21, 2021- 
April 21, 2022 
Wheelchair and Leg 
Rests 
20% $11.04 
TOTAL:   $729.12 
 
The SNF stay falls within the Skilled nursing facility (SNF) care benefit category. The wheelchair and leg rests 
fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the SNF stay, wheelchair and leg rests provided from March 1, 2022, 
through April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the complete denture - maxillary 
(D5110) and mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214) provided September 7, 2021. 
 
You asked the Plan to provide additional payment for the complete upper and partial lower dentures. You say 
that you still do not have your dentures. The Plan denied your request. The Plan says the coinsurance has 
applied correctly. The Plan also says they have reached out to the provider who is willing to assist in fixing 
your issues. 
 
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 complete 
upper and partial lower dentures when the services are medically necessary and reasonable.  
 We looked at the file and Medicare rules. In this case you have been asked to pay a total of $610.51 ($1,526.30 
allowed amount x 40% coinsurance = $610.52) for the dentures. This means you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to 
provide additional payment for the complete denture - maxillary (D5110) and mandibular partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) 
provided September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with metal crown (D2751) for tooth #8. 
 
You asked the Plan to pre-approve the dental service. You say that the tooth is breaking down and the dental 
service is medically necessary. The Plan denied your request. The Plan says the x-rays sent are not the most 
current x-rays of the enrollee's teeth or mouth. The x-rays of the enrollee's tooth did not show that the tooth has 
a lot of the tooth missing from a cavity or has a lot of damage from being broken. 
 
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 dental 
service when the services are medically necessary and reasonable.  
 
  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 the dental service. Our reviewer says 
that the crown restoration does not meet the coverage criteria. Our physician reviewer found that the 
documentation indicates that tooth #8 does not exhibit significant coronal breakdown due to caries or fracture 
to warrant a crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a white glass with metal crown (D2751) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - four or more surfaces, posterior 
(D2394), resin-based composite - four or more surfaces, posterior (D2740), and resin-based composite - one 
surface, posterior (D2391) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services.. You say that you are requesting a reconsideration as the Plan 
is not paying what you were advised with your additional coverage. The Plan denied your request. The Plan 
says the claim for the services provided were processed 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. You have been asked to pay a total of $657.10 for the dental services. 
 
SERVICE ALLOWED AMOUNT CO-INSURANCE AMOUNT YOU OWE 
D2394 $179.00 50% $89.50 
D2740 $738.00 70% $516.60 
D2391 $102.00 50% $51.00 
TOTAL   $657.10 
 
The dental services at issue are covered by the Plans dental benefits, however you are responsible for a share 
of the costs as described above. Therefore, we decided that the Plan does not have to pay for a resin-based 
composite - four or more surfaces, posterior (D2394), resin-based composite - four or more surfaces, posterior 
(D2740), and resin-based composite - one surface, posterior (D2391) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 80307 and 83789 billed for date of service
January 17, 2022.

You asked the Plan to pay for procedure codes 80307 and 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
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, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD,
MALDI, TOF) includes sample validation when performed, per date of service.

We find that CPT code 80307 is not supported in the medical record. Specifically, only one drug test within the
presumptive drug class and one drug test within the definitive drug class per date of service is allowed. Review
of the enrollee's claim history indicates that a presumptive service has been previously submitted by another
provider for this date of service. This means this code if not separately reimbursable.

We have confirmed that code 83789 is a column II code to column I code G0481. While code 83789 was billed
with the -59 modifier, 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 codes 80307 and 83789 billed for date
of service January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0367) provided on May 25, 2022. 
 
You asked the Plan to pay for imaging. You say that you are on a fixed income and cannot afford this cost. The 
Plan denied your request. The Plan says cone beam imaging (D0367) 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 cone 
beam imaging (D0367) provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided by an out-of-network 
provider 
 
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 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 endodontic therapy (D3330) provided by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only had a cleaning this day. 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. 
 
The medical record shows you received a comprehensive oral evaluation on May 17, 2022. 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 May 17, 2021. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services (81230, 81238, 81240, 81241, 81291, and 
81479) provided on April 5, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that the documentation does not 
support payment for the services billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case the Plan has denied coverage by stating information from the 
provider was not received. However, there are test results as well as clinical records located in the case file 
despite the claims to the contrary. There is no indication these records are insufficient to be used to render a 
decision. Therefore, we decided that the Plan has to pay for the genetic testing services (81230, 81238, 81240, 
81241, 81291, and 81479) provided on April 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), removal of residual tooth 
roots (D7250), deep sedation/general anesthesia (D9222, D9223), and therapeutic parenteral drugs (D9612) 
provided on May 11, 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 the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. Additionally, the removal of residual tooth roots and therapeutic 
parenteral drugs 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. 
 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 limited oral evaluation (D0140), removal of residual tooth roots (D7250), deep sedation/general 
anesthesia (D9222, D9223), and therapeutic parenteral drugs (D9612) provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection (CPT code(s): 64495). 
 
You asked the Plan to pre-approve the facet joint injection. You say that the service is necessary. The Plan 
denied your request. The Plan says there was no additional information submitted that specifies that more than 
two bilaterally are medically necessary. 
 
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 the facet joint injection. Our physician 
reviewer found the request for a third level exceeds utilization criteria and there is no special issue raised to 
consider the third level reasonable and necessary. The third level is considered not medically reasonable or 
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the facet joint injection (CPT code(s): 64495).