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

 
We decided that the Plan does not have to pay for the testing services provided on June 21, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one code 
must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the pharmacogenetic testing was billed with multiple codes. If a single procedure is performed, 
only one code with one unit of service may be reported for the procedure. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the testing services provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seven crowns provided on October 23, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the crowns. You say that you got porcelain prosthesis on your 7 teeth, not gold 
crowns. You also say that you were told the treatment would be covered. The Plan denied your request. The 
Plan says non-emergency services provided by an OON provider are not available with this dental plan. The 
Plan also says that there are no call records on file that reflect you were advised you would be reimbursed. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the seven 
crowns provided on October 23, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram report provided on November 29, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
not separately reimbursed. 
 
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 93042 is a column II code to column I code 93010. 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 the electrocardiogram 
report provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis coded 81002 provided on October 8, 2021. 
 You asked the Plan to pay for the urinalysis. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are 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 CPT code. In this case, we have confirmed that code 81002 
is a column II code to column I code 80307. 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 the urinalysis coded 81002 provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-
rays (D0330), complete maxillary denture (D5110), and complete mandibular denture (D5120) provided on 
March 24, 2022, and April 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-rays, complete maxillary 
denture, and complete mandibular denture. You say that a Plan representative advised the clinic you went to 
accepted your insurance. The Plan denied your request. The Plan says services provided by an OON provider 
are not covered because your health care plan does not have OON benefits. The Plan also says that when you 
contacted the Plan you were advised that only services rendered by in-network providers are 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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), panoramic x-rays (D0330), complete maxillary denture 
(D5110), and complete mandibular denture (D5120) provided on March 24, 2022, and April 4, 2022 by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete mandibular dentures (D5120). 
 
You asked the Plan to pre-approve dentures. You say that due to memory issues you need another pair of 
dentures. The Plan denied your request. The Plan says this service is covered by the Plan's dental benefits; 
however, your benefits for one denture every five years has 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 covers one denture 
every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for dentures 
provided on February 21, 2021; therefore, the benefit for dentures has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve complete mandibular dentures (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on March 8, 2022. 
 
You asked the Plan to pay for a complete maxillary denture. You say that your dentures were not fitted 
correctly. You say that you needed to get your dentures fixed. The Plan denied your request. The Plan says the 
benefit limit for D5110 has already been met and 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 covers a complete 
maxillary denture once every 60 months.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a complete maxillary denture 
was provided on July 19, 2021. Based on this information, we decided that the Plan's rules for coverage of a 
complete maxillary denture have not been met. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary denture (D5110) provided by a participating provider on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive procedure on September 14, 2021 to February 16, 2022. 
 
You asked the Plan to pay for preventive procedure. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says this service isn't included in your benefit plan. 
 
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 
preventive procedure on September 14, 2021 to February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
1, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you had two evaluations with a different provider on 
the same day. The Plan denied your request. The Plan says this service is covered by your Plan's dental 
benefits; however, your benefit for one oral evaluation every six months has 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 covers one oral 
evaluation every six months. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a periodic 
oral evaluation provided on March 1, 2022; therefore, the benefit for an oral evaluation has been exhausted. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment. You say that the screw is already in your 
mouth. You say that you need this implant. The Plan denied your request. The Plan says D6057 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 pre-approve a 
custom fabricated abutment (D6057) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided February 15, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that your previous dentist retired. It was 
necessary to get a new dentist who needed to perform a new exam. The Plan denied your request. The Plan 
says you have exceeded the frequency limit for this service. 
 
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. The Plan covers the 
comprehensive oral exam once every 36 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on June 3, 2020. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (dental code D7953) and tumor 
removal (dental code D7410) for tooth #24. 
 
You asked the Plan to pre-approve bone replacement graft and tumor removal. You say that you are requesting 
reconsideration to see if the services can be approved. The Plan denied your request. The Plan says records do 
not show that the enrollee has any soft tissue, and the bone replacement graft is not a covered benefit denial. 
 
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. The Plan covers tumor 
removal when the services are medically necessary and reasonable. The Plan does not cover bone replacement 
graft. 
 
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 replacement graft and tumor 
removal. Our reviewer says that given the documentation the requested tumor removal is not medically 
reasonable and necessary, and the Plan excludes coverage for any dental implant procedures, so that bone 
replacement graft would not meet criteria. Our physician reviewer found the request is for D7410, a removal of 
a lesion 1.25 cm or smaller. There are no supplied records to indicate a separate tissue removal of a lesion aside 
from the removal of heavily broken-down tooth #24. In the case where there is a broken-down tooth there is 
often a periapical infection that exists due to the breakdown of the tooth due to bacterial infection. The infected 
area beyond the tooth often creases a sac that is removed along with the tooth. If the tissue to be removed is not 
a simple bacterial reaction and a specific procedure is performed, then a specific code should be used. The 
AAOMS states "Cyst removal, as any surgical procedure, must be accurately described and documented in the 
patient's chart. Failure to document the reason for the cyst removal and accurately describe the surgical 
procedure may lead to the claim being disallowed by the third-party payer as being inherent to the extractions." 
In this instance there is no documentation supplied that supports a separate procedure being performed or that a 
tissue sample was sent for biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of tumor removal have not been met and the requested services of the bone 
replacement graft is not among those covered under the Plan's dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve bone replacement graft (dental code D7953) and tumor removal (dental code 
D7410) for tooth #24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation of tooth 
#2 through #11, #14, and #15 (D7953), gingival irrigation of each quadrant (D4921), an immediate mandibular 
(lower) partial denture (D5224), and caries (tooth decay/cavities) risk assessment and documentation with a 
finding of high risk (D0603). 
 You asked the Plan to pre-approve the dental services. You say that you are low-income and cannot afford to 
pay for the needed services on the amount you receive from Supplemental Security Income (SSI). You say you 
need approval of partial permanent dentures in order for your gums to heal so you can get permanent teeth 
later. Your primary concern is regarding the approval of the necessary services to treat your gum 
disease, so you can proceed with additional dental treatments. The Plan denied your request. The Plan says the 
requested dental services are not covered by the Plan's 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 pre-approve bone 
replacement grafts for ridge preservation of tooth #2 through #11, #14, and #15 (D7953), gingival irrigation of 
each quadrant (D4921), an immediate mandibular (lower) partial denture (D5224), and caries (tooth 
decay/cavities) risk assessment and documentation with a finding of high risk (D0603).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) provided by a participating 
provider. 
 
You asked the Plan to pre-approve endosteal implants. You say that you need these implants so you can chew. 
The Plan denied your request. The Plan says the requested services 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 
endosteal implants (D6010) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on February 2, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
re-cement or re-bond crown. You say that these services were rendered due to an emergency and you could not 
wait to get your tooth fixed. The Plan denied your request. The Plan says these services were rendered by an 
OON provider. The Plan also says that you did not contact the Plan prior to the date of service to determine if 
you would be covered for services from an OON dental 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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond 
crown (D2920) provided on February 2, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on February 15, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider 
provided by June 14, 2021. 
 
You asked the Plan to pay for dental services. You say that you thought the Plan would pay for more. The Plan 
denied your request. The Plan says the maximum dental allowance amount has already been met and 
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 covers dental 
services up to a $1,500 dental allowance.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider provided by June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #22 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the enrollee needed new dentures. The Plan denied 
your request. The Plan says a crown (D2740) is 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 pre-approve a 
crown on tooth #22 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and consultation 
- diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) 
provided March 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extraction and dental consultation. You say that you were not informed 
that the oral surgeon was not part of the Plan's network. The Plan denied your request. The Plan says these 
services are not covered when provided OON. 
 
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. The Plan covers the tooth 
extraction and dental consultation when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. In this case the provider who rendered the services are not part of the 
Plan's dental network. Based on this information, we decided that the Plan's rules for coverage of the tooth 
extraction and dental consultation have not been met. Therefore, we decided that the Plan does not have to pay 
for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation 
of mucoperiosteal flap if indicated (D7210) and consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided March 25, 2022, by an out-of-network 
(OON) provider.  
 
Your complaint about not feeling adequately informed about the provider's network status prior to receiving 
the services 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.