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

 
We decided that the Plan does not have to pre-approve a consultation - diagnostic service provided by dentist 
or physician other than requesting dentist or physician (D9310) performed by an endodontist. 
 
You asked the Plan to pre-approve a consult with an endodontist. You say that you need a specialist to evaluate 
your teeth. The Plan denied your request. The Plan says dental services are not covered when performed by an 
endodontist. 
 
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 certain dental 
services when performed by a participating general dentist. 
 
We looked at the file and Medicare rules. In this case the requested service will be performed by an 
endodontist. Based on this information, we decided that the Plan's rules for coverage of a dental consult have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) performed by an 
endodontist.
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 with field of view of one full dental arch and 3 surgical placement of implant body. 
 
You asked the Plan to pre-approve a cone beam CT capture and interpretation with field of view of one full 
dental arch and 3 surgical placement of implant body. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services 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, 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 with field of view of one full dental arch and 
3 surgical placement of implant body.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary overdenture (D5863), a partial 
mandibular overdenture (D5866), and six custom fabricated abutments (D6057 x6). 
 
You asked the Plan to pre-approve the complete maxillary overdenture, partial mandibular overdenture, and 
custom fabricated abutments. You say that these services are for medical treatment, not cosmetic needs. The 
Plan denied your request. The Plan says these procedures are not included in the benefits section of your 
Evidence of Coverage. 
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 
complete maxillary overdenture (D5863), a partial mandibular overdenture (D5866), and six custom fabricated 
abutments (D6057 x6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary overdenture (D5864). 
 
You asked the Plan to pre-approve the partial maxillary overdenture. You say that you have not received any 
kind of partial overdenture to cover the screws that have been implanted. The Plan denied your request. The 
Plan says this service is allowed one time in 5 calendar years. The Plan also says that you have already reached 
the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 1 of either codes 
D5110, D5211, D5213, D5221, D5223, D5225, D5227, D5863, D5864, D6110, or D6112 once per 5 calendar 
years. The record shows that you received a maxillary partial denture (D5213) on February 11, 2020 and your 
maxillary denture benefit has been exhausted.  
 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary overdenture (D5864).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Muscle, myocutaneous, or fasciocutaneous flap (15733 
and 15733-59) provided on January 15, 2020. 
 
You asked the Plan to pay for codes 15733 and 15733-59. You say that the medical records support the billing 
of codes 15733 and 15733-59 provided on January 15, 2020. The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 15733 and 15733-59 provided on January 15, 2020. 
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 also 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 15733 is Muscle, myocutaneous, or fasciocutaneous flap; 
head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, 
sternocleidomastoid, levator scapulae). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 15733 and 15733-59. Our reviewer says that the 
medical records do not support the billing of codes 15733 and 15733-59 provided on January 15, 2020. Our 
reviewer found the record indicates that the enrollee underwent a procedure.  The record indicates that flaps 
were raised and advanced.  The record does not indicate that a named vascular pedicle flap was created. The 
elements of the coverage criteria are not satisfied.  The requested service is not recommended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 15733 and 15733-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for the Muscle, myocutaneous, or fasciocutaneous flap (15733 and 15733-59) 
provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 extractions, anesthesia, and alveoloplasty. 
 
You asked the Plan to pre-approve these services. You say that you have repeated toothaches and need the 
extractions for dentures. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plan covers only simple extractions. The extractions are not 
covered by your medical benefit because they are not being done to prepare the jaw for radiation treatments. 
The alveoloplasty and anesthesia are not listed as covered benefits. Therefore, we decided that the Plan does 
not have to pre-approve 13 extractions, anesthesia, and alveoloplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown for teeth #30 and #31 (D2799) to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve an interim crown. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the benefit limit for D2799 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 crown per 
tooth every 60 months.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a crown was provided for teeth 
#30 and #31 on October 25, 2021. Based on this information, we decided that the Plan's rules for coverage of 
an interim crown have already been met. Therefore, we decided that the Plan does not have to pre-approve an 
interim crown for teeth #30 and #31 (D2799) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310) and three surgical extractions 
(D7210 x3) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the consultation and surgical extractions. You say that you are in pain and 
cannot afford to pay for an oral surgeon. You also say that a regular dentist does not want to do the procedure 
because the tooth is close to a nerve. The Plan denied your request. The Plan says your contract with the Plan 
only provides coverage for dental services when they are performed by a participating general dentist. The Plan 
also says that dental services performed by an oral surgeon 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 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation (D9310) and three surgical extractions (D7210 x3) to be 
provided by an oral surgeon.
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 November 9, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you don't feel you should have been 
billed for the previous comprehensive exam. The Plan denied your request. The Plan says you have exceeded 
the frequency limit for this service. The Plan also says they are reviewing your concerns about your previous 
exam. 
 
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 oral 
exam was previously covered on July 15, 2021. 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 November 
9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DME (CPT code(s) E2311, E2377, and E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. E2377 Expandable Controller, E2313 
Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are 
requested to control power tilt, recline and power elevating leg rests through the joystick. The notes state that 
these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be 
covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. Documentation shows 
that the member has 3+/5 strength in the upper limbs with full ROM. Upper limb strength and function are 
adequate for the member to be able to control the power options using their own switches which are included in 
the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve the 
DME (CPT code(s) E2311, E2377, and E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second intraoral x-ray provided on December 31, 2021. 
 
You asked the Plan to pay for the second intraoral x-ray. You say that this service was necessary and was 
provided as part of a dental emergency. You also say you were told the services you received would be 
covered. The Plan denied your request. The Plan says your dental benefit covers a maximum of one intraoral x-
ray per calendar year. You received two on the date in question. One of these x-rays was covered and paid for 
by the Plan, but the second intraoral x-ray exceeds the Plan's frequency limitation for this service. In addition, 
the Plan states that the call history was reviewed and there were no calls from either you or the provider 
regarding your benefits for the services on the date in question. 
 
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 can cover one 
intraoral x-ray per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-ray is requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the second intraoral x-ray provided on December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth #'s 8 and 9. 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says the x-rays do 
not show that tooth #'s 8 and 9 require additional structure to support and retain crowns. 
 
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 core 
buildups 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 core buildups. Our reviewer says 
that the imaging does not support that core buildup, including any pins when required, for tooth #'s 8 and 9 are 
reasonable and necessary for the enrollee in this case. Our physician reviewer found tooth #'s 8 and 9 do not 
have sufficient damage from decay or injury to necessitate core buildups. Our reviewer also found that there 
appears to be sufficient tooth structure to support a crown.  
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 core buildups have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildups, including any pins when required (D2950) for tooth #'s 8 and 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4211) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that this service was necessary. The 
Plan denied your request. The Plan says this service is not covered by your dental 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 the 
gingivectomy or gingivoplasty (D4211) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the prefabricated abutment and implant supported crown. You say that you 
are on a low income and are unable to pay out of pocket for these services. The Plan denied your request. The 
Plan says these services are not covered under your 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 a 
prefabricated abutment (D6056) and implant supported crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower overdenture (D5865). 
 
You asked the Plan to pre-approve an overdenture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered by your dental 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 pre-approve a 
complete lower overdenture (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #28 and a prefabricated post 
and core in addition to crown (D2954) for tooth #28. 
 
You asked the Plan to pre-approve the crown and prefabricated post and core. The Plan denied your request. 
The Plan says the requested dental services are covered when there is extensive decay or destruction of the 
tooth where the tooth cannot be fixed with only a filling. The Plan also says that crowns for cosmetic reasons or 
for closing gaps 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. The Plan covers the crown and 
prefabricated post and core 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 crown and prefabricated post and 
core. Our reviewer says that given the case presentation, there would be no necessity for the requested 
treatment on tooth #28. Our physician reviewer found tooth #28 has a large distal and occlusal restoration that 
does not provide a good contact with tooth #29. You stated in the record that as tooth #28 is a very deep 
restoration, that a "prophylactic" endodontic procedure needs to be performed and then a post and core and 
crown. Though the restoration does appear large on the provided x-ray, there is no clear need for an 
interventional root canal therapy so that a post and crown can be placed. Our reviewer found that the tooth 
would be amenable to a replacement restoration, even if needing to extend the restoration to the mesial aspect 
(extend to 3 surfaces) for retention. There are two involved surfaces, and the Plan requires that the tooth be 
otherwise unrestorable before crown restorations are to be considered. Our physician reviewer also found that 
in this case there is sufficient ability to replace the existing restoration and no clear need for root canal 
treatment. 
 
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 crown and prefabricated post and core have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a crown (D2740) for tooth #28 and a prefabricated post and 
core in addition to crown (D2954) for tooth #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedures (D1999), bone replacement graft 
of the first site in quadrant (D4263), bone replacement grafts of each additional site in quadrant (D4264), and 
guided tissue regenerations (D4266) provided on September 9, 2021, and September 17, 2021. 
 
You asked the Plan to pay for the preventive procedures, bone replacement grafts, and guided tissue 
regenerations. You say that you went to a contracted dentist and the services were billed to you directly. You 
also say that you were only informed that you had to pay the copayment when your Evidence of Coverage 
states you have zero copayments. The Plan denied your request. The Plan says the bone replacement grafts and 
guided tissue regenerations are not covered dental codes. 
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. Since the bone replacement grafts and guided tissue regenerations are 
not covered by your plan, the services described by code D1999 are also not covered. Therefore, we decided 
that the Plan does not have to pay for the preventive procedures (D1999), bone replacement graft of the first 
site in quadrant (D4263), bone replacement grafts of each additional site in quadrant (D4264), and guided 
tissue regenerations (D4266) provided on September 9, 2021, and September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on November 1, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that you would like to be reimbursed for this 
service. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. 
 
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 bone 
replacement graft for ridge preservation (D7953) provided on November 1, 2021.