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

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray 
(D0270), and to pay more for the crown (D2740) provided on August 4, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the core buildup, problem focused limited oral evaluation, first intraoral 
periapical x-ray, bitewing x-ray, or pay more for the crown. You say that you assumed the treating provider 
was in-network because they have done work on you before. You also say that you were not advised that the 
dentist who provided the crown was not in-network. The Plan denied your request. The Plan says core buildup 
is not a covered expense under your dental plan. The Plan says that your benefits for the problem focused 
limited oral evaluation, first intraoral periapical x-ray, and bitewing x-ray have been satisfied, and the 
frequency limitations have been exceeded. The Plan also says that these services were performed by a non-
participating provider, and you are responsible for any difference between the Maximum Allowable Fee and 
the amount the provider bills you for the covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when 
required (D2950) is not among those covered under this benefit. The Plan contract says that emergency 
diagnostic exam, intraoral x-rays, and bitewing x-rays are each limited to 1 procedure code per calendar year. 
The record shows that you received a problem focused limited oral evaluation (D0140), first intraoral 
periapical x-ray (D0220), bitewing x-ray (D0270) on January 19, 2022, and these benefits have been exhausted. 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the crown (D2740). 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 pay for the core buildup, including 
any pins when required (D2950), problem focused limited oral evaluation (D0140), first intraoral periapical x-
ray (D0220), bitewing x-ray (D0270), and to pay more for the crown (D2740) provided on August 4, 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 the intraoral radiographic image (D0220) provided on March 
22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you did not ask the provider for additional x-
rays. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
intraoral radiographic image is not covered 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 
intraoral radiographic image (D0220) provided on March 22, 2022.  
  Your complaint about the provider not asking to do additional x-rays 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 pay for the dental services on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring provided on April 14, 2022. 
 
You asked the Plan to pay for remote patient monitoring. The Plan denied your request. The Plan says that the 
Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent 
care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for remote patient monitoring provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on 
September 12, 2022. 
 
You asked the Plan to pay for the fixed partial denture sectioning (D9120). You say that you are requesting 
reconsideration as this service was necessary. You also say that the dental bridge needed to be cut and 
sectioned by the dentist in order to reconstruct your left bottom jaw. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 fixed 
partial denture sectioning (D9120) provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
tooth #'s 11, 14, 19, 22, 27 and 30 (D6010), overdentures  complete mandibular (D5865), and complete 
maxillary (D5863). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant tooth #'s 11, 14, 
19, 22, 27 and 30 (D6010), overdentures  complete mandibular (D5865), and complete maxillary (D5863). 
You say that you need to get special dentures because the regular dentures cause you pain. The Plan denied 
your request. The Plan says these services are not covered under the benefit package. 
 
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 
surgical placement of implant body: endosteal implant tooth #'s 11, 14, 19, 22, 27 and 30 (D6010), 
overdentures  complete mandibular (D5865), and complete maxillary (D5863).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and fundus photography with 
interpretation and report (92250) provided on August 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and fundus photography. You say that you thought the treating 
provider was contracted. The Plan denied your request. The Plan says you received these services from a 
provider who is not part of the Plan's approved vision provider network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan-approved vision provider. 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received these services from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and fundus 
photography have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
(92014) and fundus photography with interpretation and report (92250) provided on August 11, 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 an oral evaluation (D0150), intraoral radiographic images 
(D0210), and the prophylaxis (D1110) provided on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental provider told you that they are an in-
network provider with the 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 an oral evaluation (D0150), intraoral radiographic images (D0210), and the prophylaxis (D1110) 
provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain fused to 
predominantly base metal (D2751) provided on 
 
You asked the Plan to provide additional payment for the crown. You say that this service was rendered by a 
network provider and should be covered. The Plan denied your request. The Plan says the coinsurance was 
applied correctly to this service. 
 
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 the crown 
with 50% coinsurance. 
 
We looked at the file and Medicare rules. You have been asked to pay $428.50 ($857 allowed amount x 50% 
coinsurance = $428.50) for the crown. 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 provide additional payment for the crown - 
porcelain fused to predominantly base metal (D2751) provided on
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided 
on July 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you feel this claim was denied incorrectly 
because the dental provider was listed on the list of contracted dental providers. You also say that you would 
have not gone to a dental provider that was not 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 the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), and panoramic x-ray (D0330) provided on July 20, 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 core buildup, including any pins when required (D2950) 
provided on August 29, 2022. 
 
You asked the Plan to pay for the dental service. You say that it is the major dental work that you need help 
paying and this needs to be covered by insurance. The Plan denied your request. The Plan says this service is 
not covered under your contract. 
 
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 core 
buildup, including any pins when required (D2950) provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5225) provided on June 15, 
2022. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you would like to appeal this service. 
The Plan denied your request. The Plan says this service is not a covered expense under your dental 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 
maxillary partial denture (D5225) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression stocking/sleeve identified with code 
A6549. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression 
stocking/sleeve identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on August 16, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you need this denture because 
you are unable to eat and are losing weight quickly. The Plan denied your request. The Plan says this procedure 
is not 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. 
 
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 
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 dental services on August 3, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for angiography, extremity, bilateral, radiological supervision and 
interpretation provided to the enrollee on July 1, 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 that the denied code cannot be verified. 
 
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 75716 is "Angiography, extremity, bilateral, radiological supervision and interpretation." 
 
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 supported by the medical records. Our reviewer found that the documentation supports the code 
as billed. Diagnostic angiography is not bundled with 37225 and is separately billable if there has been no 
previous recent angiography or if there has been a change in condition. In this case, there is documentation that 
there has been no recent angiogram for this clinical scenario. The details of the bilateral extremity angiogram 
are sufficiently documented to support the billing and coverage of 75716. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
angiography, extremity, bilateral, radiological supervision and interpretation provided to the enrollee on July 1, 
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 an unspecified periodontal procedure (D4999) provided on 
August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed if you did not receive this 
procedure, your health could be in jeopardy. The Plan denied your request. The Plan says services that are not 
listed in the Patient Charge Schedule 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 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 an 
unspecified periodontal procedure (D4999) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on August 18, 2022. 
 
You asked the Plan to pay for the x-rays. You say that without taking new x-rays the dentist would not have 
known that you had a cavity. 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 February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on August 18, 
2022.