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

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310), the cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws (D0367), and the surgical placement of an implant 
body: endosteal implant (D6010) provided on August 18, 2021 and September 17, 2021. 
 
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 the dental services provided in this case 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service provided by a dentist or physician other than requesting dentist or physician (D9310), the 
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367), and 
the surgical placement of an implant body: endosteal implant (D6010) provided on August 18, 2021 and 
September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve comprehensive orthodontic treatment. You say that the enrollee needs this 
service. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occusal guard (D9944) and a crown (D2751), 
provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to have an exception and 
receive this dental work. The Plan denied your request. The Plan says your benefit for D2751 has already been 
exhausted. The Plan says that D9944 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, certain limitations apply. The record 
shows your benefit for D2751 was exhausted on date of service September 16, 2020. D9944 is not a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve an occusal guard (D9944) and a 
crown (D2751), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve fixed partial denture sectioning. You say that you would like an exception 
because you cannot afford the cost of this service. The Plan denied your request. The Plan says this service is 
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 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 fixed 
partial denture sectioning (D9120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81408, 81162, 81292, 81321, and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 25, 2021, billed with codes 81408, 81162, 81292, 81321, and 81407.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core build up on tooth #2 and 14 (D2950) and a crown on tooth #2 
and 14 (2752). 
 
You asked the Plan to pre-approve core build up and crowns. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says that the services do not meet the coverage criteria. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to determine if the Plan provided the correct coverage criteria. Therefore, we 
decided that the Plan has to pre-approve core build up on tooth #2 and 14 (D2950) and a crown on tooth #2 and 
14 (2752).  
 
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 pre-approve to recement an implant supported crown (D6092 x 3). 
 
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 recement an implant supported crown (D6092) is not 
covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve to 
recement an implant supported crown (D6092 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns on tooth #18, 19, 20, 21, 22, 
24, 25, 28, 29, 30, and 31 (D6065) and prefabricated abutments on tooth #18, 19, 20, 21, 22, 24, 25, 29, 30, and 
31 (D6056). 
 
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 implant supported crowns (D6065) and prefabricated 
abutments (D6056) are 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 pre-approve 
implant supported crowns on tooth #18, 19, 20, 21, 22, 24, 25, 28, 29, 30, and 31 (D6065) and prefabricated 
abutments on tooth #18, 19, 20, 21, 22, 24, 25, 29, 30, and 31 (D6056).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) delivery and set up 
services (A9901) provided on May 3, 2021. 
 
You asked the Plan to pay for code A9901. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says no separate payment can be made for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 CPT code A9901 has a status code of "X" under the MPFSDB and represents a service that is not in the 
statutory definition of "physician services" for fee schedule payment purposes. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment (DME) delivery and set up services (A9901) 
provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided from November 18, 2021, to 
December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were misguided by plan representatives 
several times. The Plan denied your request. The Plan says you received these services from a provider who 
chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided from November 18, 2021, to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation. You say that a bone 
replacement graft for ridge preservation is medically necessary. The Plan denied your request. The Plan says 
dental code D7953 is not listed, and therefore 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 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 
bone replacement graft for ridge preservation (D7953).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2021, billed with 
codes 81206 and 81235. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 13, 2021, billed with codes 81206 and 81235.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported lower denture; lower arch (D6111). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant 
supported lower denture; lower arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments  includes modification and 
placement (D6056), implant supported porcelain/ceramic crowns (D6065), and surgical placement of implant 
body: endosteal implants (D6010). 
 
You asked the Plan to pre-approve prefabricated abutments, implant supported crowns and endosteal implants. 
You say that you need the implants to eat properly. 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 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 prefabricated abutments  includes modification and placement (D6056), implant supported porcelain/ceramic 
crowns (D6065), and surgical placement of implant body: endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - nonresorbable barrier, per 
site (includes membrane removal) (D4267). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that the enrollee needs this service. The 
Plan denied your request. The Plan says this service is not covered under the enrollee's benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) (D4267).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete 
denture (D5110), and mandibular partial denture (D5214), provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need this additional denture because your 
first pair is not useable. 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 comprehensive oral evaluation was exhausted on date of service January 13, 2021. 
Additionally, your benefit for the complete denture and mandibular partial denture was exhausted on date of 
service January 19, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150), complete denture (D5110), and mandibular partial denture (D5214), provided on February 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment on tooth #10 (D6056) and an 
abutment supported crown on tooth #10 (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says a prefabricated abutment (D6056) and an abutment supported crown 
(D6058) are 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 
prefabricated abutment on tooth #10 (D6056) and an abutment supported crown on tooth #10 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided on April 18, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that you were never informed you 
had a cost sharing amount. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 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 $15 
copayment for per service during the visit for covered routine dental services when provided by an in-network 
provider.  
 
You have been asked to pay $15 copayment for each dental service. Prophylaxis and a periodic oval evaluation 
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. Therefore, we decided that the Plan does not have to waive the copayment for prophylaxis 
(D1110) and a periodic oral evaluation (D0120) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigationper quadrant (D4921 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the services at issue are not a covered benefit under 
the enrollees 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival 
irrigationper quadrant (D4921 x 4).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on January 21, 2022. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services were medically necessary 
and were pre-approved. The Plan denied your request. The Plan says the payment for this service is always 
bundled into the payment for another item/service. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (code D0150), panoramic film (code 
D0330), images (code D0210), and CT scan (code D0367) provided on March 1, 2022. 
 
  You asked the Plan to pay for the dental services. You say that you verified the provider was in-network. The 
Plan denied your request. The Plan says the oral evaluation, panoramic film, and images, were received from 
an out-of-network provider and are not covered by your supplemental benefits. The Plan also says the CT scan 
is not on the list of covered dental services. 
 
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 oral evaluation, panoramic film, and images from an out-of-network 
provider. The record also shows the CT scan is not a covered supplemental dental benefit. 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 and when they are not listed on the dental benefits 
chart. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (code 
D0150), panoramic film (code D0330), complete series of radiographic images (code D0210), and cone beam 
computed tomography (CT) scan (code D0367) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve incisional biopsy of oral tissue. You say that the service is necessary. The 
Plan denied your request. The Plan says the requested service 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 pre-approve 
incisional biopsy of oral tissue (D7286).