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

 
We decided that the Plan does not have to pre-approve apicoectomy  molar (first tooth) (D3425) and 
retrograde filling  per root (D3430) Tooth #19. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services to prevent 
infection or any other health issues. The Plan denied your request. The Plan says this service is not covered 
under 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. Apicoectomy  molar (D3425) 
and retrograde filling  per root (D3430) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested apicoectomy  molar 
(first tooth) (D3425) and retrograde filling  per root (D3430) Tooth #19 are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve apicoectomy  molar (first tooth) 
(D3425) and retrograde filling  per root (D3430) Tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture of 
both jaws (D0367), a radiographic/surgical implant (D6190) for tooth 25, the surgical placement of an 
endosteal implant (D6010) for teeth 22, 24, 25, and 27, and a bone graft at the time of implant placement 
(D6104) for teeth 22, 24, 25, and 27. 
 
You asked the Plan to pre-approve a cone beam computed tomography (CT) capture of both jaws (D0367), a 
radiographic/surgical implant (D6190) for tooth 25, the surgical placement of an endosteal implant (D6010) for 
teeth 22, 24, 25, and 27, and a bone graft at the time of implant placement (D6104) for teeth 22, 24, 25, and 27. 
You say that you were told that implants would be covered. You also say you would like your implants to be 
covered. The Plan denied your request. The Plan says these services are not covered under 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 
cone beam computed tomography (CT) capture of both jaws (D0367), a radiographic/surgical implant (D6190) 
for tooth 25, the surgical placement of an endosteal implant (D6010) for teeth 22, 24, 25, and 27, and a bone 
graft at the time of implant placement (D6104) for teeth 22, 24, 25, and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Prolia injection (J0897) and therapeutic
injection (96372) provided on May 26, 2022.
You asked the Plan to waive the cost share for the Prolia injection (J0897) and therapeutic injection (96372).
You say that this has never had an out-of-pocket expense before, and you are being billed incorrectly. The Plan
denied your request. The Plan says this cost sharing was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $335
copayment for surgery or other services provided to you at an outpatient hospital, including but not limited to
hospital or other facility charges and physician or surgical charges.
You have been asked to pay $246.34 for the Prolia injection and therapeutic injection.
Date of Service Service Plan Allowance Cost Per Contract Your
Responsibility
May 26, 2022 Prolia Injection (J0897) $932.64 20% coinsurance $186.53
May 26, 2022 Therapeutic Injection
(96372)
$59.81 $335 copayment $59.81
TOTAL: $246.34
The Prolia injection falls within the Medicare Part B prescription drugs benefit category. The therapeutic
injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities
and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the
Prolia injection (J0897) and therapeutic injection (96372) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are denied due to no completely healed 
implant noted on your radiograph. This treatment can be resubmitted once proof of complete healing of the 
implant can be demonstrated by your provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and a radiographic image 
(D0270) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and your dentist needed to do 
these services to figure out what was wrong. 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 services was exhausted on the date of service of March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) and a radiographic 
image (D0270) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device (D9944) provided from April 19, 
2021, to November 23, 2021. 
 
You asked the Plan to pay for the occlusal orthotic device (D9944). You say that you submitted this claim to 
both dental and medical insurance. You say the claim was not paid under either. The Plan denied your request. 
The Plan says the service is purely dental in nature and cannot be covered under the dental plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
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 the occlusal orthotic device (D9944). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation did 
not contain a definitive diagnosis of TMJ dysfunction related to a medical condition. There was an indication 
of cold sensitivity and denied bruxism. Therefore, the criteria for coverage were not met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the occlusal orthotic device (D9944) have not been met. Therefore, we decided 
that the Plan does not have to pay for the occlusal orthotic device (D9944) provided from April 19, 2021, to 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation (D9310) by an endodontist. 
 
You asked the Plan to pre-approve the dental service. You say that you were referred to the dentist for a root 
canal. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because root canals are not covered by the Plan and dental services by an endodontist are also 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 an 
evaluation (D9310) by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure, by report 
(D5899) provided on June 22, 2022. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure, by report (D5899). You say 
that you told the dentist prior to receiving services you did not want anything done that would not be covered 
by insurance. 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 pay for an 
unspecified removable prosthodontic procedure, by report (D5899) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) and 
intravenous moderate (conscious) sedation/analgesia services (D9243) provided on November 19, 2021. 
 
You asked the Plan to pay for the scalings and planings and intravenous moderate (conscious) 
sedation/analgesia services. You say that you would like to appeal these services. The Plan denied your request. 
The Plan says the group coverage plan is terminated, and the Plan no longer administers benefits for this group 
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 
periodontal scalings and root planings (D4341) and intravenous moderate (conscious) sedation/analgesia 
services (D9243) provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 14, 2021, to April 29, 2021.

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 the provider has reported inpatient hospital services with the incorrect DRG.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with A41.9 - sepsis, unspecified organism. 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that the review has determined that the use of A41.9 - sepsis unspecified organism - was not an appropriate diagnosis for this stay. Laboratory data revealed a platelet count of 265 and a total bilirubin of 0.7. In this case, the SOFA score was 1 based on the elevated creatinine. Therefore, the diagnosis of sepsis was  not valid according to Sepsis-3 criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 14, 2021, to April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation- new or established patient 
(D0150) provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your first provider was not a good reliable 
dentist, so you had to go to a different dentist. 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. Comprehensive oral 
evaluation- new or established patient (D0150) is a covered benefit once every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation- new or established patient (D0150) was 
exhausted on date of service January 6, 2020. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation- new or established patient (D0150) provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial upper denture (D5211), and full mouth debridement 
(D4355) provided on June 1, 2022. 
 
You asked the Plan to pay for a partial upper denture, and full mouth debridement. You say that you were told 
these services would be covered. The Plan denied your request. The Plan says the cost share of these services 
was applied 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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a partial upper denture, and full mouth debridement have not been met. Therefore, we decided that 
the Plan does not have to pay for a partial upper denture (D5211), and full mouth debridement (D4355) 
provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740), core buildup (D2950), addition to a 
crown (D2954), root canal (D3310), and an extraction (D7120). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get 
these dental procedures done. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the enrollee does not have routine or supplemental dental benefits with the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740), core 
buildup (D2950), addition to a crown (D2954), root canal (D3310), and an extraction (D7120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6010, D6057, D6059, D4263, D4265) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 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 
dental services (D6010, D6057, D6059, D4263, D4265)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration and bone replacement graft 
(D7953, D4266) 
 
You asked the Plan to pre-approve guided tissue regeneration and bone replacement graft. You say that the 
services should be covered as you disagree with the denial. 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 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 
guided tissue regeneration and bone replacement graft (D7953, D4266)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5110) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 21, 2022. 
Therefore, we decided that the Plan does not have to pre-approve dentures (D5110)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 18, 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 services received are not covered 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 dental 
services on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on December 8, 
2021. 
 
You asked the Plan to pay for the dental service. You say that the provider told you the dental procedure would 
be covered, and you would like the Plan to pay for the service. The Plan denied your request. The Plan says 
bone grafts are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a bone replacement graft 
(D7953) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic service consultation (D9310) provided on July 20, 
2022. 
 
You asked the Plan to pay for diagnostic service consultation (D9310). You say that you verified coverage 
prior to your visit, including the visit in question, with the Plan's customer service. The Plan denied your 
request. The Plan says the service or item in question is not covered under your contract under any normal 
circumstances. 
 
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 rules say that any 
services not listed in the EOC are not covered. 
 
 
  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 diagnostic 
service consultation (D9310) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you do not have money for this. The Plan 
denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), radiographic images (D0220 and 
D0230) provided on June 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were directed to an in-network provider and 
the services should be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the dental codes are not listed on the dental benefits chart; therefore, they are 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 an oral 
evaluation (D0140), radiographic images (D0220 and D0230) provided on June 11, 2022.