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

We decided that the Plan does not have to pay for an oral evaluation (D0140), periapical radiograph (D0220)
and a crown restoration (D2740) provided on January 7, 2021.
You asked the Plan to pay for these services. You say that these dental services were medically necessary. You
submitted additional dental records directly to Maximus for review. The Plan denied your request. The Plan
says the services provided were not covered under your Plan contract. Maximus overturned the Plans denial
stating the services provided were necessary for the dental health of your teeth. The Plan requested a reopen
and stated that the issue was not medical necessity but the fact that dental services are supplemental, and the
services provided were not covered under Medicare or your Plan contract.
The Plan is correct in this case. Medicare does not cover dental services. The Plan contract you were a member
of for 2021 did not cover routine dental services. While these services may have been appropriate for you, they
were not covered by Medicare nor the Plan on the date of service in question.
Therefore, we decided that the Plan does not have to pay for oral evaluation (D0140), periapical radiograph
(D0220) and a crown restoration (D2740) provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #9 (D2950) and a composite filling on 
tooth #10 (D2335) provided on February 22, 2022. 
 
You asked the Plan to pay for core build up and a filling. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are covered by your dental benefits; however, your 
annual maximum allowance has 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. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows your annual maximum 
allowance for preventive and comprehensive dental services has been exhausted during the processing of this 
claim. Therefore, we decided that the Plan does not have to pay for core build up on tooth #9 (D2950) and a 
composite filling on tooth #10 (D2335) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts at the time of implant placement (D6104), 
surgical implants (D6010), cone beam imaging (D0364) and collection and application of autologous blood 
concentrate (D7921). 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not covered by the enrollee's dental 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 
bone grafts at the time of implant placement (D6104), surgical implants (D6010), cone beam imaging (D0364) 
and collection and application of autologous blood concentrate (D7921).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the electrocardiogram (EKG) and laboratory 
services provided on November 5, 2021. 
 You asked the Plan to waive the charges for the EKG and lab services. You say that you feel that you should 
not owe more than the $175 copayment to the facility for this procedure. You believe that the $52 you were 
billed is incorrect. The Plan denied your request. The Plan says the claims were processed 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 $175 
copayment for diagnostic procedures and tests performed in the outpatient hospital setting.  
 
You have been asked to pay $52.59 for the EKG. This is the Medicare allowed amount for this service when 
provided in the outpatient hospital setting and is less than the applicable cost share of $175 for this type of 
service. The lab testing provided on the same date is not separately payable when provided with an EKG. The 
$52.59 is the entire Medicare allowable for the services billed on this claim. 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. This cost sharing is for a different date of service 
than the surgical copayment and is therefore not included in that copayment. Therefore, we decided that the 
Plan does not have to waive the charges for the electrocardiogram (EKG) and laboratory services provided on 
November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that your previous dentist that made your 
dentures did not make them right. You say that it is now giving you issues. You also say that you have not been 
able to eat correctly. The Plan denied your request. The Plan says partial dentures are covered once every 60 
months. The Plan also says that the frequency limit has been reached. 
 
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 and partial dentures are listed as 
covered, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that 
you received on February 16, 2022. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210), 
periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and topical application of 
fluoride varnish (D1206) provided February 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete series of x-rays, periodic oral exam, dental cleaning and fluoride 
varnish. You say that you are an established patient with this provider. Additionally, this provider is the closest 
provider to you. The Plan denied your request. The Plan says these services are not covered because they were 
provided OON. The Plan also says there are 2 network providers within 30 miles of your house. 
 
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 contract says that 
you are responsible for 100% of the cost of dental services provided OON. 
 We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the complete series of x-rays, periodic oral exam, dental cleaning and fluoride varnish have not been met. 
Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic images 
(D0210), periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and topical 
application of fluoride varnish (D1206) provided February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autograft for spine surgery (20936) provided on August 11, 2020. 
 
You asked the Plan to pay for autograft for spine surgery (20936). You say that the surgery was detailed and 
required assistance. You say that previous treatments failed, and the claim should be paid. The Plan denied 
your request. The Plan says bundled services are not eligible for separate payment. 
 
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 20936 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20936 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of autograft for spine surgery (20936) have not been met. Therefore, we decided that the Plan does not have to 
pay for autograft for spine surgery (20936) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950), provided by a 
participating provider on October 14, 2021. 
 
You asked the Plan to pay for a crown and a core build-up. You say that these services were necessary. The 
Plan denied your request. The Plan says these services have been processed correctly. 
 
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 one crown per 
calendar year. The Plan does not include a core build-up. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2740 was provided and paid 
for on October 16, 2021. Based on this information, we decided that the Plan's rules for coverage of a crown 
have not been met. The Plan does not cover a core build-up. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core build-up (D2950), provided by a participating provider on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310), and extractions (D7210 x15). 
 
You asked the Plan to pre-approve a consultation and extractions. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says extractions are only covered 8 times per 
calendar year, and you have exceeded that limit. The Plan also says you are over the age limit for the 
consultation coded D9310 to be 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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a consultation and extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a consultation (D9310), and extractions (D7210 x15).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3331) performed by an endodontist. 
 
You asked the Plan to pre-approve a root canal. You say that your tooth is getting infected. You also say that 
you cannot find a dentist in-network to do the root canal. The Plan denied your request. The Plan says dental 
services must be performed by a participating general dentist. The Plan also says that a root canal (D3331) is 
not covered by the Plan's 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 a 
root canal (D3331) performed by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on June 25, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
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 until February 15, 2023. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant /abutment supported removable denture for 
edentulous arch - mandibular (D6111) provided March 30, 2022. 
 
You asked the Plan to pay for the implant supported removable denture. You say that you cannot afford the 
cost of this service. The Plan denied your request. The Plan says this service is not covered under your benefits. 
Additionally, services provided out-of-network 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant /abutment supported removable denture for edentulous arch - mandibular (D6111) provided March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120), 
prophylaxis (D1110), and resin-based composite filling (D2391, D2392) provided on February 2, 2022. 
 
You asked the Plan to waive the coinsurance for an evaluation, prophylaxis, and fillings. You say that your 
dental benefits have an allowance of $2,000 every year. 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 50% coinsurance for out-of-network non-Medicare covered preventive and comprehensive services. The contract 
says the Plan pays up to $2,000 every year for non-Medicare covered preventive dental services and non-
Medicare covered comprehensive dental services combined. 
 
The record shows you received services from an out-of-network provider on February 2, 2022.  The record also 
shows these claims were approved, and you have a cost sharing amount. You have been asked to pay 50% 
coinsurance for an evaluation, prophylaxis, and fillings.  
 
Code Allowed Amount 50% Coinsurance 
D0120 $70 $35 
D1110 $119 $59.50 
D2391 $238 $119 
D2392 $304 $152 
 
An evaluation, prophylaxis, and fillings 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 coinsurance for a periodic oral evaluation (D0120), prophylaxis (D1110), and resin-
based composite filling (D2391, D2392) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided January 11, 2022. 
 
You asked the Plan to pay for the crowns and core buildup. You say that your insurance broker gave you bad 
information about coverage. The Plan denied your request. The Plan says these services are not covered under 
your benefits. The Plan also says they have investigated and could not find evidence of incorrect information 
being provided by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
crowns - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided 
January 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 10, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 10, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 10, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of July 10, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond July 10, 2022, as he was not a danger to himself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 10, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 10, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 9, 2022, to February 12, 2022. 
 
You asked the Plan to pay for dental services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says covered services must be provided by a participating provider. 
 
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 covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider on February 9, 2022, 
to February 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), mandibular complete denture (D5120), and semi-precision attachment on tooth #23, 25, and 27 
(D6192) provided on March 7, 2022. 
 
You asked the Plan to pay for an evaluation, x-ray, denture, and attachments. You say that you disagree with 
the denial for dental services. The Plan denied your request. The Plan says a comprehensive oral evaluation 
(D0150), panoramic x-ray (D0330), and mandibular complete dentures (D5120) are not covered by the Plan's 
dental benefits when received by an out-of-network provider. The Plan also says that semi-precision 
attachments (D6192) are not covered by the Plan's dental 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. 
 
The record shows the enrollee received dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, a comprehensive oral evaluation (D0150), panoramic x-
ray (D0330), and mandibular complete dentures (D5120) are not among those covered under this benefit when 
received by an out-of-network provider. Semi-precision attachments (D6192) are not covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
panoramic x-ray (D0330), mandibular complete denture (D5120), and semi-precision attachment on tooth #23, 
25, and 27 (D6192) provided on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5845, L5828, L5848, L5856) 
for a prosthetic leg. 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested item 
have not been met. 
 
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 a microprocessor knee. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the available records do not document trial and failure of a mechanical K3 knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee (L5845, L5828, L5848, L5856) for a prosthetic leg.