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

 
We decided that the Plan does not have to pay for the dental services on April 20, 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 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 October 6, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 17, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are allowed two dental cleanings per year. 
You also say that the service was nothing more than a cleaning, no x-ray, no service by the 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. 
 
 
  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 April 29, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4266) and a bone replacement 
graft (D4263) provided on April 6, 2022. We also decided that the Plan does not have to waive the deductible 
and the coinsurance for osseous surgery (D4260) provided on April 6, 2022. 
 
  You asked the Plan to pay for guided tissue regeneration (D4266) and a bone replacement graft (D4263). You 
also asked the Plan to waive the deductible and the coinsurance for osseous surgery (D4260). You say that you 
received the approval for the procedure, and that your total responsibility was $35. The Plan denied your 
request. The Plan says guided tissue regeneration (D4266) and a bone replacement graft (D4263) are not 
covered under your dental plan. The Plan also says this cost sharing for osseous surgery (D4260) was charged 
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. Guided tissue regeneration 
(D4266) and a bone replacement graft (D4263) are not covered by the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a 40% coinsurance after your $1,000 Plan deductible, which applies to 
Medicare-covered physician specialist services (including for osseous surgery (D4260). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, guided tissue regeneration (D4266) 
and a bone replacement graft (D4263) are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for guided tissue regeneration (D4266) and a bone replacement graft 
(D4263) provided on April 6, 2022.  
 
You have been asked to pay $1,000 toward the deductible for osseous surgery (D4260). You have also been 
asked to pay an additional $160, which is 40% of the allowed amount (minus the deductible) for the osseous 
surgery ($400 allowed amount after the deductible x 40% coinsurance = $160). Osseous surgery (D4260) falls 
within the out-of-network, Medicare-covered physician specialist services (including surgery) benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 40% coinsurance after 
your $1,000 Plan deductible, which applies to Medicare-covered physician specialist services (including 
surgery). This cost sharing is a contractual obligation that had not been met at the time osseous surgery 
(D4260) was received on April 6, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible and the coinsurance for osseous surgery (D4260) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve deep sedation/general anesthesia, each subsequent 15-minute 
increment (code D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia, each subsequent 15-minute increment. 
You say that deep sedation/general anesthesia, each subsequent 15-minute increment is medically necessary. 
The Plan denied your request. The Plan says that the additional time requested is not medically necessary to 
safely complete the requested dental procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pre-approve deep sedation/general anesthesia, each 
subsequent 15-minute increment. Our reviewer says that the requested deep sedation/general anesthesia, each 
subsequent 15-minute increment is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation provided indicating the surgical procedures to be performed meets the 
criteria for coverage for the anesthesia services requested by the surgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of deep sedation/general anesthesia, each subsequent 15-minute increment have 
been met. Therefore, we decided that the Plan has to pre-approve deep sedation/general anesthesia, each 
subsequent 15-minute increment (code D9223).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user-adjustable heel height feature represented by 
code L5990. 
 
You asked the Plan to pre-approve a user-adjustable heel height feature. You say that the records provided 
support the need for all of the items requested. The Plan denied your request. The Plan says the item which 
remains in dispute is not considered reasonable and necessary by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a user-adjustable heel height feature will be 
denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a 
user-adjustable heel height feature represented by code L5990.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that bone marrow aspirate is experimental. More research is needed to demonstrate the safety 
and effectiveness of the requested service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939) for spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that regardless of what prior care was given, you 
believe that due to your particular dental history that you are entitled to this coverage as medical and dental 
necessity. 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. The Plan rules say that these 
services are covered once every three years. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for intraoral - complete series of radiographic images (D0210) was exhausted on date of 
service July 20, 2020. The record also shows your benefit for a comprehensive oral evaluation (D0150) was 
exhausted on date of service November 12, 2020. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation (D0150) and intraoral - complete series of radiographic images (D0210) 
provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nitrous oxide (D9230) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that you needed this procedure due to your anxiety 
and you would like the Plan to pay for it. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because nitrous oxide 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 
nitrous oxide (D9230) provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness 
and electronic connection between wheelchair controller and two or more power seating system motors. 
 
You asked the Plan to pre-approve expandable controller, expandable controller harness and electronic 
connection between wheelchair controller and two or more power seating system motors. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. The rules say that a group 3 power wheelchair accessories are only 
covered for certain indications. 
 
Review of the file shows that the documentation does not support a medical need to control these power 
options through the joystick. The documentation supports that the enrollee is independent with self-feeding. 
The documentation shows that the enrollee has paraplegia. Upper limb strength and function are adequate for 
the enrollee to be able to control the power options using their own switches which are included in the 
allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller, expandable controller harness and electronic connection between wheelchair controller 
and two or more power seating system motors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), cone beam computed 
tomography (CT) capture and interpretation with limited field of view (D0364), and pulp vitality tests (D0460) 
provided on November 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover this 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 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 limited oral exam was exhausted on date of service December 8, 2021. This benefit does not include cone beam CT scans or pulp vitality tests as covered services. Therefore, we decided that the 
Plan does not have to pay for the limited oral exam (D0140), cone beam computed tomography (CT) capture 
and interpretation with limited field of view (D0364), and pulp vitality tests (D0460) provided on November 
24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction of tooth #31 (D7140), endosteal implants 
on tooth #29 and 30 (D6010), and an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says dental services from an out-of-network provider 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 an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an extraction of tooth #31 (D7140), endosteal implants on tooth #29 and 30 (D6010), and an occlusal guard 
(D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation for dental implants provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve a consultation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a consultation is covered but not when received by an oral 
surgeon. 
 
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 item or service is not 
among those covered under this benefit when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a consultation for dental implants provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve a specialist visit. You say that your cancer is rare and aggressive. You say
that the provider you are requesting specializes in this type of cancer. The Plan denied your request. The Plan
says you can receive the care you need within the health plan network.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extractions (D7140 and D7210) and the
anesthesia (D9222 and D9223) for tooth #15 and #18 provided on June 23, 2022.

You asked the Plan to reimburse you for the dental services. You say that you would like the Plan to reimburse
you for the already paid dental services. The Plan denied your request. The Plan says the denial of
reimbursement for these services is correct, because extractions are not covered by the Plan and anesthesia is
only covered when it is needed with a covered procedure.

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 reimburse you for
the extractions (D7140 and D7210) and the anesthesia (D9222 and D9223) for tooth #15 and #18 provided on
June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 21, 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 21, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) for tooth #15 
provided on July 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you believe that the provider billed the wrong 
service code for the service that was rendered. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because removal of residual tooth roots is not covered by the Plan. Also, the 
Plan confirmed with the provider that the proper code was billed for the service that was rendered. 
 
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 
removal of residual tooth roots (D7250) for tooth #15 provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a 
participating provider on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the partials you currently have are poorly made. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 4, 2018. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a 
participating provider on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4267), surgical 
placement of implant body: endosteal implant (D6010), implant supported porcelain/ceramic crown (D6065), 
and bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve a guided tissue regeneration, endosteal implant, implant supported 
porcelain/ceramic crown, and bone replacement graft. You say that if the tooth is not fixed, it will affect your 
health, especially your blood problem. You also say that the tooth is already infected, and you have sickle cell 
disease. The Plan denied your request. The Plan says these services are not covered under your 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 a 
guided tissue regeneration (D4267), surgical placement of implant body: endosteal implant (D6010), implant 
supported porcelain/ceramic crown (D6065), and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a CT cone beam 
capture (D0381) provided by a participating provider on June 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services done. The Plan 
denied your request. The Plan says your benefit for D0140 has already been exhausted. D0381 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, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service January 7, 2022. This benefit does not include 
D0381. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a 
CT cone beam capture (D0381) provided by a participating provider on June 17, 2022.