Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 48 units of procedure code 87798 billed for date of service 
February 14, 2022. 
 
You asked the Plan to pay for 48 units of code 87798. You say that these services were necessary and ordered 
by a network provider. The Plan denied your request. The Plan says they have agreed to pay for the other 
services provided on this date; however, there is a medically unlikely edit (MUE) for this service which indicates 
that it would be medically highly unlikely that more than 13 units of 87798 on a single day would be 
both reported correctly and medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of 48 units of code 87798 have been met. 
Specifically, medical records were not submitted to support that this service was reported correctly and was 
medically necessary. Therefore, we decided that the Plan does not have to pay for 48 units of procedure code 
87798 billed for date of service February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a socket insert (L5658). 
 
You asked the Plan to pre-approve a socket insert. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the requested additional socket insert cannot be approved. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of prosthetic 
accessory. Based on the Medicare rules, your request exceeds the number of socket inserts allowed. Therefore, 
we decided that the Plan does not have to pre-approve a socket insert (L5658).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #3, 8, and 9 (D7210) provided on March 
31, 2022. 
 
You asked the Plan to pay for the extractions. You say that you were advised that you were in-network with the 
enrollee's plan. The Plan denied your request. The Plan says the enrollee's 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted on date of service March 31, 2022. 
Therefore, we decided that the Plan does not have to pay for extractions of tooth #3, 8, and 9 (D7210) provided 
on March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care admission. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that please consider and approve this 
authorization so the enrollee can proceed with surgery. The Plan denied your request. The Plan says The 
approved planned procedure listed under CPT code 23472, 23430, 23020 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is undergoing a planned left total shoulder arthroplasty, tenodesis, 
capsular contracture release. The enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The planned procedure listed under CPT code 23472, 23430, 23020 is not 
listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There 
is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight 
stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a cone beam 
computed tomography capture and interpretation (D0367), two-dimensional oral/facial photographic images 
(D0350), an intraoral complete series of radiographic images (D0210), teeth cleaning (D1110), topical 
application of fluoride (D1206), and oral hygiene instructions (D1330) provided on June 3, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you thought the services were fully covered. 
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), a cone beam computed tomography capture and 
interpretation (D0367), two-dimensional oral/facial photographic images (D0350), an intraoral complete series 
of radiographic images (D0210), teeth cleaning (D1110), topical application of fluoride (D1206), and oral 
hygiene instructions (D1330) provided on June 3, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided by a participating 
provider on May 20, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like reimbursement for these 
services. 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 resin-
based composite (D2391) provided by a participating provider on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75726 billed for date of service October 26, 2021. 
 
You asked the Plan to pay for procedure code 75726. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 75726 is bundled into payment for code 37243. 
 
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, we have confirmed that code 75726 
is a column II code to column I code 37243. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 75726 billed for date of service October 26, 2021.
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) 
provided April 13, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you were told crowns would be covered. 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 pay for the core 
buildup, including any pins when required (D2950) provided April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to fully pay for a porcelain/ceramic crown provided on March 24, 2022. 
 
You asked the Plan to fully pay for a porcelain/ceramic crown. You say that you were informed that this 
service should be covered. The Plan denied your request. The Plan says that the dental service has been paid on 
the least costly method of treatment and you will be responsible for the remaining balance. 
 
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 the file, Evidence of Coverage and Medicare rules. Based on this information, we decided that the 
Plan's rules for full coverage of a porcelain/ceramic crown have been met. Specifically, the Evidence of 
Coverage does not state that porcelain/ceramic crowns are not customary treatment. This means that the Plan 
did not clearly disclose a ceramic crown would be covered instead of the porcelain/ceramic and you cannot be 
held liable for the difference in cost. Therefore, we decided that the Plan has to fully pay for a 
porcelain/ceramic crown provided on March 24, 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 pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve a partial upper denture and a lower partial denture. You say that the 
requested services are medically necessary. The Plan denied your request. The Plan says the requested services 
are not a covered benefit of your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to 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 a limited oral evaluation (D0140) and endodontic therapy on 
tooth #29 (D3320) provided on April 26, 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 the dental services were received from an out-of-network provider 
and are not covered by the enrollees supplemental benefits without prior authorization. 
 
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 the requested dental services were received 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 without prior authorization. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) and endodontic therapy on 
tooth #29 (D3320) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service was necessary for your implants to 
be removed. 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 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 31, 2022.
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 September 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have seen this provider for years and do not 
wish to change dentists. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 99215 provided on 
November 1, 2021. 
 
You asked the Plan to pay for an additional unit of procedure code 99215. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 99215 are not supported in the medical record. The medical record only supports 1 unit of CPT code 99215. Based on this information, we decided that Medicare rules for coverage of 
an additional unit of procedure code 99215 have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 99215 provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and teeth cleaning 
(D1110) provided on June 6, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the office staff verified they were in-network 
and then scheduled you with a provider that 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 periodic oral evaluation (D0120) and teeth cleaning (D1110) provided on June 6, 2022, by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment of dental pain on tooth #3 (D9110) 
provided on June 23, 2022. 
 
You asked the Plan to pay for palliative treatment. You say that this was an emergency because you had a bad 
infection. The Plan denied your request. The Plan says palliative treatment of dental pain (D9110) is 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 palliative 
treatment of dental pain on tooth #3 (D9110) provided on June 23, 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 September 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 1, 2022. 
 
You asked the Plan to pay for procedure code 99140. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99140 is considered bundled and not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 5, 2022. 
 
You asked the Plan to pay for a consultation. You say that this service should have been billed as an 
examination. The Plan denied your request. The Plan says the service at issue 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 
consultation (D9310) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a metal crown (D2751) and a core build-up (D2949) 
provided by an out-of-network provider on January 10, 2022. 
 
You asked the Plan to pay for a metal crown and a core build-up. You say that the Plan says that they cover 
restorative services. 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 metal 
crown (D2751) and a core build-up (D2949) provided by an out-of-network provider on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the dental services provided on April 13, 2022. 
 
You asked the Plan to waive the cost for the dental services. You say that you only had one diagnostic x-ray, 
two teeth extractions, one filling and one scaling treatment. You say that all other services the dentist billed are 
false. The Plan denied your request. The Plan says the services were performed, and the claim processed 
correctly according to the Plan contract. 
 
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, you have a $50 deductible that applies 
to basic and major dental services. Once your $50 deductible is met you also pay 20% of the cost for resin-
based composites (D2332 and D2335) and extractions (D7210). You are responsible for the full cost of the 
bone replacement graft (D7953) as it is not a covered benefit. The records show the services were provided. 
This means that the claim processed correctly according to your EOC. Therefore, we decided that the Plan does 
not have to waive the cost for the dental services provided on April 13, 2022.