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

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided by a network 
provider on November 22, 2021. 
 
You asked the Plan to pay for the limited oral evaluation (D0410). You say that the procedure was not done as 
a routine visit. You say it was performed to determine how to reduce the swelling and infection. The Plan 
denied your request. The Plan says the service exceeded the frequency limitation in the benefit 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 limited oral evaluation (D0140) is 
not among those covered under this benefit. The record shows the benefit for the limited oral evaluation benefit 
was met on November 16, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided by a network provider on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the core build up (D2950) provided on 
December 7, 2021. 
 
You asked the Plan to pay the in network rate for the core build up. You say that your dentist referred you to 
this endodontist for this root canal. You also say there are zero endodontist in network. The Plan denied your 
request. The Plan says core build up is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay the in network rate for the core build up (D2950) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 24, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you saw a new dentist, and it 
has been 7 to 8 months since your last exam within the Plan's guidelines. The Plan denied your request. The 
Plan says this service exceeds the frequency limitation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 9, 2020 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need teeth removed in 
order to get dentures. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus mandibularis (D7473)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing 
provided on August 19, 2021, billed with codes 88365-TC and 88365-TC-XU. 
 
You asked the Plan to pay for the FISH testing as billed. You say that the records support that this testing was 
performed and was medically necessary. The Plan denied your request. The Plan says the POS code used is not 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FISH testing as billed have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing provided on August 
19, 2021, billed with codes 88365-TC and 88365-TC-XU.
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 on 
June 28, 2021, to October 18, 2021. 
 
You asked the Plan to pay for dental services. You say that you were never notified that you reached your 
maximum allowance amount. The Plan denied your request. The Plan says the benefit maximum amount of 
$1,500 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 covers dental 
services with a maximum allowance amount of $1,500.  
 
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 already been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on June 28, 2021, to October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay 
more for the surgical extraction (D7210) provided on November 10, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and to pay more for the surgical 
extraction. You say that you have had trouble going to different dentists, so you chose better ones. The Plan 
denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency 
limitation under your dental plan. The Plan also says that you are responsible for your copayment, plus the 
difference between the dentist's total submitted amount and the Plan's total allowed amount for services 
rendered by a non-participating dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to two oral exams per 
calendar year. The record shows that you received oral exams on March 3, 2021, and September 8, 2021 and 
your oral exams benefit has been exhausted. You are also responsible for a $75 deductible, plus a 30% 
coinsurance for the extraction, plus the difference between the billed amount and allowed amount of the 
extraction because it was received OON. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) or pay more for the surgical extraction (D7210) provided on 
November 10, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 35206 and 38999 are not supported. 
 
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, the CPT Code Manual definition of code 35206 is repair blood vessel, direct; upper extremity. The 
definition of code 38999 is unlisted procedure, hemic or lymphatic system.  
 
We find that CPT codes 35206 and 38999 are not supported in the medical record. Specifically, there is no 
documentation of direct repair of a blood vessel of an upper extremity to support code 35206. There is no 
documentation of an unlisted procedure of the hemic or lymphatic system to support code 38999. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services rendered on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that you would like to appeal this 
service due to medical necessity because of the discomfort you are in. The Plan denied your request. The Plan 
says this service is not covered under 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 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 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted procedure, dentoalveolar structure 
(D41899). 
 
You asked the Plan to pre-approve an unlisted procedure, dentoalveolar structure. You say that you disagree 
with the denial and would like to appeal the decision. The Plan denied your request. The Plan says the 
requested service is not a covered benefit with the enrollee's 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 an 
unlisted procedure, dentoalveolar structure (D41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower 
denture (D5120), an interim complete upper denture (D5810), and an interim complete lower denture (D5811). 
 
You asked the Plan to pre-approve the dental items. You say that the dentures are necessary. The Plan denied 
your request. The Plan says the claim denied 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 requested dentures are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110), a complete lower denture (D5120), an interim complete upper denture (D5810), and an 
interim complete lower denture (D5811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the house/extended care facility calls (D9410) provided from 
June 29, 2021, to August 9, 2021. 
 
You asked the Plan to pay for the house/extended care facility calls. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says this service 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 the 
house/extended care facility calls (D9410) provided from June 29, 2021, to August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline maxillary partial denture (D5760) provided by an 
out-of-network provider on November 15, 2021. 
 
You asked the Plan to pay for a reline maxillary partial denture. You say that you think that the Plan should pay 
for more than 15%. The Plan denied your request. The Plan says services provided by an out-of-network 
provider can be billed for any amount greater than the payment made 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 a reline 
maxillary partial denture (D5760) provided by an out-of-network provider on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that in 2020 when you received your dental card, 
you contacted the Plan and were advised that you did not have coverage. You also say that in 2021 when you 
received another dental card, you spoke with a representative who told you that you did have coverage both 
years and you would have submitted the claim sooner if you had known you had coverage in 2020. The Plan 
denied your request. The Plan says this claim was submitted after the timely filing limit set by your plan. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until January 6, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the dental services provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a re-cemented crown 
(D2920) provided by an out-of-network provider on December 15, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and a re-cemented crown. You say that you would like 
the Plan to pay for these services. The Plan denied your request. The Plan says D0140 and D0220 are not 
covered 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 limited 
oral evaluation (D0140), and a re-cemented crown (D2920) provided by an out-of-network provider on 
December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 31, 2022, 
forward. 
You asked the Plan to pre-approve inpatient psychiatric care from March 31, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
31, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 31, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond March 31, 2022, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 31, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 31, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) 
provided by an out-of-network provider on November 5, 2021. 
 
You asked the Plan to pay for prophylaxis and a periodic oral evaluation. You say that this provider should be 
in-network. The Plan denied your request. The Plan says services provided by an out-of-network provider 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. The Plan covers prophylaxis 
and a periodic oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis and a periodic oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-network provider on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia (D9222) and problem 
focused limited oral evaluation (D0140) provided on September 9, 2021. 
 
You asked the Plan to pay for the deep sedation/general anesthesia and problem focused limited oral 
evaluation. You say that the whole point in going to an in-network dentist is so that you do not have to pay the 
full amount that is billed. The Plan denied your request. The Plan says the deep sedation/general anesthesia is 
not a covered benefit. The Plan also says that the problem focused limited oral evaluation exceeds the 
maximum count per period allowed for this procedure code. 
 
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, deep sedation/general anesthesia 
(D9222) not among those covered under this benefit. The contract says that you are limited to two exams per 
calendar year. The record shows that you received a problem focused limited oral evaluation (D0140) on 
January 14, 2021, and a periodic oral evaluation (D0120) on March 16, 2021 and your exams benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia 
(D9222) and problem focused limited oral evaluation (D0140) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair/scooter. 
 
You asked the Plan to pre-approve a power wheelchair/scooter. You say that you fall often, are unable to get up 
and need multiple surgeries. You also say you have a torn rotator cuff and cannot move or get around without 
assistance. The Plan denied your request. The Plan says records do not show that your ADLs are significantly 
impacted to the point where you truly meet the criteria for a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. Your 
condition can be improved by a walker and the Plan has approved this item. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair/scooter.