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

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274), and intraoral - periapical first 
radiographic image (D0220) provided February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that these services are covered under your plan. 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 prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), bitewings - 
four radiographic images (D0274), and intraoral - periapical first radiographic image (D0220) provided 
February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral 
periapical radiographic images (D0220), bitewing radiographic images (D0272), and teeth cleaning (D1110) 
provided on February 7, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-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 a comprehensive oral evaluation (D0150), intraoral periapical radiographic images (D0220), 
bitewing radiographic images (D0272), and teeth cleaning (D1110) provided on February 7, 2022, by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodontal maintenance (D4910) provided on April 21, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that this cleaning should be covered. The Plan 
denied your request. The Plan says that periodontal maintenance is not covered without a history of periodontal 
therapy within the last 24 months. The Plan also says that they paid the least costly treatment method. 
 
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 medical records to show if you have had periodontal 
therapy within the last 24 months. Without the medical records we are also unable to determine if the least 
costly treatment method would produce a satisfactory result. Therefore, we decided that the Plan has to pay for 
periodontal maintenance (D4910) provided on April 21, 2022.  
 
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 pay for the additional intraoral periapical x-rays (D0230) provided 
on March 28, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you believe these x-rays 
should be covered because the provider needed new x-rays. 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 March 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-rays (D0230) 
provided on March 28, 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 April 19, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 March 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 September 8, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) 
provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) and the topical application 
of fluoride varnish (D1206) provided on May 12, 2022. 
 
You asked the Plan to pay for periapical x-rays and fluoride varnish. You say that you were never told these 
services were not covered. The Plan denied your request. The Plan says periapical x-rays (D0220, D0230) and 
topical application of fluoride varnish (D1206) are not covered by your supplemental 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 periapical 
x-rays (D0220, D0230) and the topical application of fluoride varnish (D1206) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment (D6057) and an abutment supported crown 
(D6058), provided by an out-of-network provider on January 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 an abutment (D6057) and an abutment supported crown (D6058), provided by an out-of-network 
provider on January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-axial rotation unit represented by code L5986. 
 
You asked the Plan to pre-approve a multi-axial rotation unit. You say that the prosthetic which remains in 
dispute is medically necessary. The Plan denied your request. The Plan says there is no documentation of a 
need for the L5986 from the medical provider. The Plan says that this item exceeds the enrollee's needs. 
 
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 multi-axial rotation unit. Our reviewer 
says that a multi-axial rotation unit is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no supporting documentation provided to show that the enrollee is at a K3 functional level. This would include documentation showing that the enrollee will be using the prosthetic leg 
for more than simple walking and would explain the need for an advanced foot feature instead of a regular foot 
feature. 
 
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 multi-axial rotation unit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a multi-axial rotation unit represented by code L5986.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 1, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you need a follow-up with your dentist every 
three months due to your dental history. 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 dates of service February 25, 2021, and 
June 30, 2021. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mandibular partial denture (D5214) 
provided on October 14, 2021, and the Plan does not have to pay for retainer crowns on tooth #6, 10, and 11 
(D6750) and pontics on tooth #7, 8, and 9 (D6240) provided on November 30, 2021. 
 
You asked the Plan to waive the coinsurance for a partial denture and to pay for crowns and pontics. You say 
that you were told these services would be covered under your medical benefit if they were not covered by your 
dental plan. The Plan denied your request. The Plan says you were charged the correct cost sharing amount for 
a partial denture (D5214). The Plan also says that retainer crowns (D6750) and pontics (D6240) are not 
covered by your dental benefits. 
 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 70% 
coinsurance for an in-network partial denture.  
 
You have been asked to pay $548.10, which is 70% coinsurance of the allowed amount for a partial denture 
($783 allowed amount x 70% coinsurance = $548.10). A partial denture falls 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.  
 
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, retainer crowns (D6750) and pontics 
(D6240) are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to 
waive the coinsurance for a mandibular partial denture (D5214) provided on October 14, 2021, and the Plan 
does not have to pay for retainer crowns on tooth #6, 10, and 11 (D6750) and pontics on tooth #7, 8, and 9 
(D6240) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the abutment supported crown (D6058) 
provided on March 31, 2022, by the out-of-network provider. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you were not notified of 
the change in dental vendor. The Plan denied your request. The Plan says the cost share amount was applied 
correctly. You say that the dentist was not notified either. You also say that you would like additional payment 
to be made. The Plan says out-of-network providers may bill you for any amount greater than what the plan 
pays. The Plan also says the change in Dental Vendor was announced in the Annual Notice of Changes for 
2022. 
 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 and the services is listed as covered, 
there are cost share amounts that apply. Additionally, out-of-network providers may bill you for any amount 
greater than what the plan pays. The record shows there is a 50% coinsurance for the covered plan allowance 
after the $100 annual deductible is met. The claim was billed with a charge of $1,850. The covered plan 
allowance is $508.25, less the $100 deductible = $408.25 x 50% coinsurance = $204.13. Therefore, we decided 
that the Plan does not have to pay an additional amount for the abutment supported crown (D6058) provided on 
March 31, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 14, 2020, and a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
July 21, 2020. 
 
You asked the Plan to pay for the evaluations and prophylaxis. You say that these claims were submitted to the 
wrong insurance company. The Plan denied your request. The Plan says these claims were submitted after the 
timely filling limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for evaluations and prophylaxis was not filed until March 1, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 14, 2020, and a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012) performed by a 
chiropractor on April 5, 2022. 
 
You asked the Plan to pay for mechanical traction therapy. The Plan denied your request. The Plan says the 
mechanical traction therapy is not covered by the plan under any circumstance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012) performed by a chiropractor on April 5, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 9, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is 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 pay for a 
consultation (D9310) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you would not have any out-
of-pocket expense. 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 June 14, 2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a resin-based composite filling on tooth #1 (D2391) provided on April 
21, 2022. 
 
You asked the Plan to pay for a filling. You say that this service should be covered. The Plan denied your 
request. The Plan says that an alternative benefit was the least costly treatment method. 
 
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 medical records to show if an amalgam filling would 
provide a satisfactory result. Therefore, we decided that the Plan has to pay for a resin-based composite filling 
on tooth #1 (D2391) provided on April 21, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided to the enrollee on 
March 9, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says the hospital provided necessary medical care to the patient, and treatment should be reimbursed. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) 
provided to the enrollee on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95861 provided 
on March 31, 2022. 
 
You asked the Plan to pay for the needle electromyography services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. 
 
We find that CPT code 95861 is not supported in the medical record. Specifically, the medical records do not 
support that needle electromyography; 2 extremities with or without related paraspinal areas was performed. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided 
that Medicare rules for coverage of the needle electromyography services have not been met. Therefore, we 
decided that the Plan does not have to pay for the needle electromyography services coded 95861 provided on 
March 31, 2022.