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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 18, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed to have 
your crown re-cemented that came off. You also say that this was not a routine visit. The Plan denied your 
request. The Plan says you exceeded the frequency limit for dental exams. 
 
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, exams are limited to two procedures 
per calendar year. The record shows that you received periodic oral evaluations (D0120) on March 12, 2021, 
and September 17, 2021 and your exams benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation (D0140) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on December 
22, 2021. 
 
You asked the Plan to pay for the resin-based composite. You say that the reason you exceeded the frequency 
limitation was because you broke a piece off of a tooth. The Plan denied your request. The Plan says your 
benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, restorations (fillings) are limited to two 
procedure codes per calendar year.  
The record shows that you received a resin-based composite of four or more surfaces (D2335) on September 8, 
2021, and a resin-based composite of three surfaces (D2393) provided on October 11, 2021 and your 
restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2391) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays 
(D0274), and prophylaxes (D1110) provided from August 4, 2020, to September 7, 2021 by a Medicare opt out 
provider. 
 
You asked the Plan to pay for the periodic oral evaluations, bitewing x-rays, and prophylaxes. You say that the 
provider you were treated by has been your long-time dentist, and you were not informed that this provider had 
opted out of Medicare. You also say that had you known of the policy change, you would have opted to see a 
different dental provider. The Plan denied your request. The Plan says you received these services from a 
provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of 
Medicare effective November 9, 2015, to November 9, 2023. 
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 a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), and prophylaxes 
(D1110) provided from August 4, 2020, to September 7, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 4, 2021. 
 
You asked the Plan to pay for physician's services. You say that this provider stopped taking insurance, but you 
thought that your PPO Plan would still partially cover out of network services. The Plan denied your request. 
The Plan says to receive payment for covered Medicare items or services from either Medicare (in the case of 
an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must 
be enrolled in the Medicare program. 
 
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 
physician's services provided on October 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83789 is 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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen.  
We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
a complete description of the procedure code being performed. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic image (D0350), and panoramic x-ray 
(D0330) provided on December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that x-ray coverage was assumed at your bi-annual 
cleaning. You say that the x-rays were never discussed with you. You say that the front desk advised you did 
not owe anything for the visit. You also say that you should not be responsible for this bill. The Plan denied 
your request. The Plan says 2D photographic image is not listed as a covered service. The Plan says that 1 full 
mouth or panoramic x-ray is covered per calendar year. The Plan also says that the frequency limit has been 
exceeded. 
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 2D photographic image is not 
among those covered under this benefit. Additionally, though panoramic x-ray is listed as covered, the record 
shows that the Plan paid for a full mouth x-ray that you received on December 2, 2021. Therefore, we decided 
that the Plan does not have to pay for the 2D photographic image (D0350), and panoramic x-ray (D0330) 
provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of one surface (D2330) and 
additional resin-based composite of two surfaces (D2331) provided on November 1, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you were told that the Plan would cover 
the fillings. You also say that you were not told the Plan would only cover two fillings. The Plan denied your 
request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been 
exceeded. The Plan says that the provider contacted the Plan on October 29, 2021, prior to the date of service, 
to verify benefits and provider eligibility. The Plan also says that on this call your provider only called in to 
verify the amount remaining on your annual dental maximum, and did not call to verify any other benefits, 
including coverage for fillings and tooth history. 
 
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, restorations (fillings) are limited to two 
procedure codes per calendar year. The record shows that you received four resin-based composites on 
November 1, 2021, two of which were covered by the Plan, and your restorations benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite of one surface (D2330) 
and additional resin-based composite of two surfaces (D2331) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2335) provided on 
November 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the resin-based composite. You say that you feel that at least 50% of the 
bill should have been paid. The Plan denied your request. The Plan says this claim processed correctly 
according to the 2021 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 Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the $100 
deductible before the Plan will pay their share for your covered dental services. You are also responsible for a 
50% coinsurance of the total cost, plus the difference between the billed amount and allowed amount because 
this service was received OON. Therefore, we decided that the Plan does not have to pay more for the resin-
based composite (D2335) provided on November 16, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found while the enrollee may be able to participate in rehabilitation therapy, the 
documentation does not support that the enrollee requires at least 15 hours of therapy services over 7 
consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) and bone graft at time of implant placement (D6104) provided October 23, 2021. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation and bone graft at the time of 
implant placement. You say that you needed emergency dental services and expected that your insurance 
would cover it. 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 pay for the bone replacement graft for ridge preservation - per site (D7953) and bone graft at time of implant placement (D6104) 
provided October 23, 2021.  
 
Your complaint about feeling that your dental coverage is inadequate is 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 pre-approve a maxillary denture (D5110) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a maxillary denture. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the benefit limit for D5110 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 Plan's coverage rules apply in this case. The Plan covers a maxillary 
denture once every five years. 
 
We looked at this physician's review, the file, and Medicare rules. Evidence was provided to show that D5110 
was provided on November 5, 2018. Based on this information, we decided that the Plan's rules for coverage of 
a maxillary denture have already been met.  

Therefore, we decided that the Plan does not have to pre-approve a maxillary denture (D5110) to be provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on March 25, 2021. 
 
You asked the Plan to pay for a crown. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crown (D6063), and an 
implant supported crown (D6065) to be provided by a participating provider. 
 
You asked the Plan to pre-approve abutment supported cast metal crown and an implant supported crown. You 
say that you need this dental work fixed. The Plan denied your request. The Plan says the requested dental 
services 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 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 
abutment supported cast metal crown (D6063), and an implant supported crown (D6065) to be provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture reline (D5751) provided on 
November 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete mandibular denture reline. You say that you would like this claim 
to be reconsidered for coverage. The Plan denied your request. The Plan says services performed by an OON 
provider are not covered because the enrollee's healthcare plan does not have OON benefits. 
 
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 enrollee is responsible for 100% of 
the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to 
pay for the complete mandibular denture reline (D5751) provided on November 10, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) and simple extraction 
(D7140) provided from October 13, 2021, to November 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the maxillary partial denture and simple extraction. You say that you would like 
to appeal these services. The Plan denied your request. The Plan says services are only covered by your Health 
Plan for in network dentists. The Plan also says that these services were rendered by an OON provider. 
 
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 OON. Therefore, we decided that the Plan does not have to pay for the 
maxillary partial denture (D5211) and simple extraction (D7140) provided from October 13, 2021, to 
November 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that you are in a lot of pain and this service is necessary in order to complete your treatment. 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 
biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953) and collection and application of autologous blood concentrate product (D7921). 
 
You asked the Plan to pre-approve a bone replacement graft and collection and application of autologous blood 
concentrate product. You say that the enrollee requires these services. The Plan denied your request. The Plan 
says these services are 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 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 - per site (D7953) and collection and application of autologous 
blood concentrate product (D7921).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on September 14, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider payment of this claim. The Plan denied your request. The Plan says the claim you submitted was an 
Outpatient Prospective Payment System (OPPS) claim.  One of the procedure codes billed (code 93352) is not 
payable, and that code needs to be corrected in order for the claim to be processed. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare sets status indicators for every 
procedure code to indicate if that code is paid under OPPS.  One of the line items you billed on this claim 
(93352) has a status indicator of M in Addendum B. According to Addendum D1, codes with a status indicator 
of M are not payable under OPPS.  So, until and unless that particular code is corrected, the entire OPPS claim 
cannot be processed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services provided on September 14, 2021.