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

 
We decided that the Plan does not have to pay more toward the maxillary partial denture (D5225) or pay for the 
topical application of fluoride (D1208) provided on January 6, 2022.  
 
You asked the Plan to pay more toward the maxillary partial denture (D5225) and pay for the topical 
application of fluoride (D1208). You say that you need to get teeth extracted and partial dentures. You say that 
this should be covered under your medical benefit because this was due to a medical issue. The Plan denied 
your request. The Plan says dental services cannot be covered under the medical benefit and the claim 
processed correctly. 
  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 Plan is only obligated to pay 50% 
of the cost for the maxillary partial denture once your $100 deductible has been met. The Plan is not obligated 
to pay for the topical application of fluoride as it is not listed as a covered benefit. Therefore, we decided that 
the Plan does not have to pay more toward a maxillary partial denture (D5225) or pay for the topical 
application of fluoride (D1208).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full series x-ray (D0210) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you changed providers so the x-ray was a 
necessary 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 August 2, 2021. 
Therefore, we decided that the Plan does not have to pay for a full series x-ray (D0210) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and topical application of 
fluoride (D0330, D1206) provided on January 19, 2022. 
 
You asked the Plan to pay for the panoramic radiographic image and topical application of fluoride. You say 
that the services should be covered as you disagree with the charges and have not met your $350 dental 
allowance yet. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 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 a 
panoramic radiographic image and topical application of fluoride (D0330, D1206) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300), a power wheelchair accessory, electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a power wheelchair accessory, expandable controller (E2377), a power 
wheelchair accessory, harness for upgrade to expandable controller (E2313), bag hooks (K0108) and a 
wheelchair accessory, lateral thigh or knee support (E0953x2). 
 
 You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee needs pressure 
relief due to being high risk for development of a pressure sore and having limited ability to shift body weight 
and position. The Plan denied your request. The Plan says there is not a medical need to control these power 
options through the joystick. The Plan also says some denied features do not serve a primary medical purpose 
and are non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300), a power wheelchair accessory, electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a power wheelchair accessory, expandable controller (E2377), a power 
wheelchair accessory, harness for upgrade to expandable controller (E2313), bag hooks (K0108) and a 
wheelchair accessory, lateral thigh or knee support (E0953x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified fixed prosthodontic procedure (D6999) 
provided by an out-of-network provider on August 18, 2021. 
 
You asked the Plan to pay for an unspecified fixed prosthodontic procedure. You say that you were told that 
these services were pre-approve. 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 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 an 
unspecified fixed prosthodontic procedure (D6999) provided by an out-of-network provider on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete interim maxillary denture (D5180) and a 
complete maxillary denture (D5110), provided by a participating provider.
 
You asked the Plan to pre-approve a complete interim maxillary denture and a complete maxillary denture. 
You say that you need these services done. The Plan denied your request. The Plan says the requested dental 
services 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 pre-approve a 
complete interim maxillary denture (D5180) and a complete maxillary denture (D5110), provided by a 
participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray transportation (R0070) and swallow studies (74230, 
74240) provided on January 3, 2022. 
 
You asked the Plan to pay for x-ray transportation and swallow studies. You say that this is supported in the 
records. The Plan denied your request. The Plan says these services cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that Place of Service (POS) 
code 11 indicates an office setting. The rules also say that concerns have been expressed that the use of 
swallow studies in a mobile setting lacks evidence of medical effectiveness. Questions of patient safety have 
yet to be resolved for these types of procedures to be performed in a skilled nursing facility, nursing home, or 
home environment, thus requiring physician presence during the procedure in such settings. This procedure 
will be reimbursed only when medically necessary and performed in office, hospital, or rehabilitation facility 
settings 
 
In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. We find that CPT code 
R0070 is not supported in the medical record. Specifically, this code is specific to transportation to a home or 
nursing home, but this was billed with POS 11 for an office setting. Swallow studies are not covered in a 
mobile setting. The record indicates that these services were provided in a mobile setting. Based on this 
information, we decided that Medicare rules for coverage of x-ray transportation and swallow studies have not 
been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation (R0070) and 
swallow studies (74230, 74240) provided on January 3, 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 October 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you told the provider you already had x-rays 
done and they did the panoramic x-ray anyways. 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 August 24, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on October 
8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0230) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should cover this benefit because it is a 
new plan year. 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 March 30, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical x-ray (D0230) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and oral evaluation (D0140, D0220) 
provided on April 27, 2022. 
 
You asked the Plan to pay for the intraoral x-ray and oral evaluation. You say that the services should be 
covered as you disagree with the denial and the services were necessary. The Plan denied your request. The 
Plan says the services denied correctly as they do not fall within 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 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 an 
intraoral x-ray and oral evaluation (D0140, D0220) provided on April 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that further utilization of the home exercise program and assistance 
from the care facility staff appears appropriate at this point. In this case, additional physical therapy is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by a 
periodontist. 
 
You asked the Plan to pre-approve the dental services. You say that your mouth is bleeding, and you are in a lot 
of pain. The Plan denied your request. The Plan says dental services from a periodontist 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. 
 
You are requesting 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 a periodontist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x 4), drugs or medicaments 
dispensed for home use (D9630), and scaling in moderate or severe gingival inflammation (D4346) provided 
on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were covered. The 
Plan denied your request. The Plan says the requested services are 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 gingival 
irrigation (D4921 x 4), drugs or medicaments dispensed for home use (D9630), and scaling in moderate or 
severe gingival inflammation (D4346) provided on April 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 18, 
2022 to March 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were no longer authorized and there were 
network providers available. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. 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 outpatient mental health services provided on January 18, 2022 to March 
8, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for core build up on tooth #20 (D2950) 
provided on September 29, 2021, and a crown on tooth #20 (D2740) provided on October 11, 2021. 
 
You asked the Plan to waive the cost share for the dental services. You say that the provider placed a crown on 
tooth #20 which did not need a crown. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. The Plan also says that you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network 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. 
 
You have been asked to pay $29.92, which is 20% coinsurance of the allowed amount for core build up 
provided on September 29, 2021 ($149.58 allowed amount x 20% coinsurance = $29.92). You have also been 
asked to pay $322.31, which is 50% coinsurance of the allowed amount for a crown provided October 11, 2021 
($644.62 allowed amount x 50% coinsurance = $322.31). You have been asked to pay the difference between 
the out-of-network providers charges and the Plans payment. 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 
cost share for core build up on tooth #20 (D2950) provided on September 29, 2021, and a crown on tooth #20 
(D2740) provided on October 11, 2021.  
 
Your complaint about the crown being done incorrectly 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular gene panel provided on May 28, 2021. 
 You asked the Plan to pay for the testing services. You say that the testing was necessary to treat the enrollee. 
The Plan denied your request. The Plan says the testing does not meet coverage criteria. 
 
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. The medical records provided do not show that the testing was 
ordered for a specific medical problem or treatment plan. Screening services such as pre-symptomatic genetic 
tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit 
and are not covered. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel provided on 
May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364), pulp 
vitality tests (D0460), and limited oral evaluation - problem focused (D0140) provided on April 27, 2022. 
 
You asked the Plan to pay for the cone beam, pulp vitality tests, and oral evaluation. You say that you were 
told by your regular dentist that the consultation and CT capture was necessary to determine if you needed a 
root canal or an extraction. The Plan denied your request. The Plan says service codes D0460 and D0364 are 
not covered benefits under your dental plan. The Plan also says that service code D0140 is a covered benefit, 
but you have exceeded the frequency limitations. 
 
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 cone beam CT capture (D0364) 
and pulp vitality tests (D0460) are not among those covered under this benefit.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for limited oral evaluation - problem focused (D0140) was exhausted on date of service 
March 28, 2022. 
 
Therefore, we decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364), 
pulp vitality tests (D0460), and limited oral evaluation - problem focused (D0140) provided on April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0394T billed for date of service October 6, 
2021. 
 You asked the Plan to pay for the services provided. You say that the medical records justify the billed 
services. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 0394T is a column II code to column I code 77401. 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 0394T 
billed for date of service October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation and 5 surgical extractions to be 
provided by an oral surgeon. 
 
You asked the Plan to pre-approve an oral evaluation and 5 surgical extractions to be provided by an oral 
surgeon. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
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 states covered dental 
services must be performed by a participating general dentist. 
 
We looked the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage 
of an oral evaluation and 5 surgical extractions to be provided by an oral surgeon have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an oral evaluation and 5 surgical extractions to be 
provided by an oral surgeon.