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

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274) and 
prophylaxis (D1110) provided on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told these services would not be 
covered. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on dates of service February 23, 2022, 
and May 12, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120), bitewings (D0274) and prophylaxis (D1110) provided on August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy (procedure code 52281) provided to the 
enrollee on June 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 52281 (1 unit) remains not supported. 
 
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, the CPT Code Manual definition of code 52881 is "Cystourethroscopy, with calibration and/or 
dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for 
cystography, male or female." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support Current Procedural Terminology (CPT) code 52281. The records show that 52000 and 51703 were 
performed.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cystourethroscopy (procedure code 52281) provided to the enrollee on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of a peri-implant defect (D6101) provided on 
August 12, 2022. 
 
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 services denied correctly as they do not fall 
within 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 a 
debridement of a peri-implant defect (D6101) provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental examination and dental x-rays provided by a 
participating provider on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told by the dentist that you 
would have to pay for this. 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 an oral exam was exhausted on date of service June 22, 2021. The record shows your 
benefit for intraoral imaging was exhausted on June 22, 2021, and August 15, 2021. Therefore, we decided that 
the Plan does not have to pay for a dental examination and dental x-rays provided by a participating provider 
on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had the dental service because you thought 
it would be covered. 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 Plan paid 
$328 for services on February 3, 2022, $759 for services on  March 7, 2022, and $413 for services on April 21, 
2022, which is the annual maximum of $1,500. The record shows your benefit for the requested item or service 
was exhausted on date of service April 21, 2022. Therefore, we decided that the Plan does not have to pay for 
dental services provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments (D6057 x2), and abutment 
supported crowns (D6058 x2) provided on July 25, 2022. 
 
You asked the Plan to pay for custom fabricated abutments, and abutment supported crowns. You say that you 
want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue 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. 
 
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 custom 
fabricated abutments (D6057 x2), and abutment supported crowns (D6058 x2) provided on July 25, 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 June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service. 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 May 21, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277) 
provided on April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to go to an out-of-network provider 
because you could not find anyone that was in-network. 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. This benefit includes only 
those items and services specifically listed in your Plan contract. Vertical bitewings - 7 to 8 radiographic 
images (D0277) is not covered under the Plans dental benefits. 
 
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 in-network or out-of-network provider. Therefore, we decided that the Plan 
does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277) provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on July 
20, 2022. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that the doctor told you this service 
was covered, and you would be responsible for 50%. The Plan denied your request. The Plan says this is not a 
covered service under your 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 fixed 
partial denture sectioning (D9120) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - four 
radiographic images (D0274) provided on July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never received any communication from 
the Plan that you had moved from a PPO plan to an HMO plan and were assigned a 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 the intraoral - periapical first radiographic image (D0220), periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) provided on July 
29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are necessary for the 
enrollee's condition. The Plan denied your request. The Plan says these items are not covered by Medicare or 
the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004). You say that you were 
misdiagnosed, therefore, your glasses are useless. The Plan denied your request. The Plan says this cost sharing 
was charged 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 a $10 
copayment for physician services to diagnose and treat diseases and conditions of the eye.   
You have been asked to pay a $10 copayment for a medical eye examination (92004). This item/service falls 
within the physician services to diagnose and treat diseases and conditions of the eye 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 a medical eye examination (92004) provided on May 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not feel you should be responsible for 
the bill. 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 May 17, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not happy with the previous service 
and are seeing a new dentist. 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 August 8, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each additional 
radiographic image (D0230) provided on August 8, 2022.  
 Your complaint about the comprehensive oral evaluation - new or established patient (D0150), panoramic 
radiographic image (D0330), and intraoral - periapical first radiographic image (D0220) services are not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to use an out-of-network provider, 
because you could not find 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. Comprehensive periodontal 
evaluation - new or established patient (D0180) is not covered under the Plans dental benefits regardless if it is 
an in-network or out-of-network provider. 
 
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 comprehensive periodontal evaluation - 
new or established patient (D0180) is not covered under this benefit when received from an in-network or out-
of-network provider. Therefore, we decided that the Plan does not have to pay for comprehensive periodontal 
evaluation - new or established patient (D0180) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 28, 2022, 
by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service. 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 periodontal maintenance (D4910) provided on July 28, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that the records support medical necessity. The Plan 
denied your request. The Plan says the services are not a benefit for the diagnosis listed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that the enrollee received cytogenetic and FISH testing for a 
diagnosis of Vitamin B-12 deficiency. This condition is not indicated for the testing provided. 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 June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230), bitewings (D0274), 
prophylaxis (D1110), and a periodic oral evaluation (D0120), provided by an out-of-network provider on April 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you verified this dentist was in-network. 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 intraoral imaging (D0220 and D0230), bitewings (D0274), prophylaxis (D1110), and a periodic oral 
evaluation (D0120), provided by an out-of-network provider on April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasopharyngoscopy surgical with dilation of eustachian 
tube (69705). 
 
You asked the Plan to pre-approve nasopharyngoscopy surgical with dilation of eustachian tube. You say that 
the service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
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 nasopharyngoscopy surgical with 
dilation of eustachian tube. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has 
bilateral hearing deficit following bilateral otitis media.  There is insufficient literature to support the safety and 
efficacy, as defined by Medicare rules, of the requested service for the enrollee's specific condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasopharyngoscopy surgical with dilation of eustachian tube have not been met. Therefore, we decided that the Plan does not have to pre-approve nasopharyngoscopy surgical with dilation of 
eustachian tube (69705).