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

 
We decided that the Plan does not have to pay more for an implant (D6010) and the anesthesia (D9222 and 
D9223) for Tooth #12 provided on November 19, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you needed an implant so you could 
properly chew your food. The Plan denied your request. The Plan says your dental benefits for the year was 
exhausted during the date of service. 
 
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 the date of service of November 19, 
2021. Prior to the date of service, the total amount paid for the yearly dental services was $695. On November 
19, 2021, the Plan paid $1,305; therefore, the yearly dental allowance of $2,000 ($695 + $1,305) was met. 
Therefore, we decided that the Plan does not have to pay more for an implant (D6010) and the anesthesia 
(D9222 and D9223) for Tooth #12 provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D6010 and D6066). 
 
You asked the Plan to pay for dental services (D6010 and D6066). You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says dental services (D6010 and D6066) are not 
covered under the member's benefit package. Dental service (D9230) has been overturned. 
 
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 dental 
services (D6010 and D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the other accessories, quickie fold down push handles 
(K0108) foam caster tire, any size (E2219). 
 You asked the Plan to pre-approve the wheelchair accessories. You say that that the medical records provided 
will show proof of medical necessity. The Plan denied your request. The Plan says says these items are either 
unbundled or not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules.  The quickie fold down push handles for wheelchair is a convenience 
item and is not covered. We have confirmed that E2219 is a Column II code to approved Column I code 
K0072. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the other accessories, 
quickie fold down push handles (K0108) foam caster tire, any size (E2219).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you lost your denture, and you would like a 
new one. 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 November 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) 
provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 28, 2022. 
 
You asked the Plan to pay for laboratory services. You say that medical records were submitted for 
reconsideration of payment on this claim. The Plan denied your request. The Plan says lab services cannot be 
separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the medical records do not support that the procedure or service was distinct or 
independent from other services performed. This code is not separately reimbursed when billed for specimen 
validity testing on specimens used for drug testing. Based on this information, we decided that Medicare rules 
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure mattress (E0184). 
 
You asked the Plan to pre-approve a mattress. You say that it is hard to breath when in a flat position. The 
enrollee needs the hospital bed that goes up 25 to 45 degrees for better breathing and to reduce leg swelling 
during the night. The Plan denied your request. The Plan says the enrollee does not qualify for the pressure 
reliving mattress. 
 
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 a mattress. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document that the enrollee is completely immobile or he has 
limited mobility and at least one of the conditions above or he has any stage pressure ulcer on the trunk or 
pelvis and at least one of conditions listed above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a mattress have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a dry pressure mattress (E0184).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillofacial prosthetic appliance (D6010) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the maxillofacial prosthetic appliance. 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 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 
maxillofacial prosthetic appliance (D6010) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth #18 (D7240) performed on 
March 1, 2022. 
 
You asked the Plan to pay for the dental extraction. You say that you paid the entire bill out-of-pocket. You say 
you received a reimbursement for another service received in the same visit and you want the Plan to pay the 
whole amount. You also say you need the payment quickly because it will affect your credit score. The Plan 
denied your request. The Plan says the specific type of extraction you received is not a covered service under 
your dental benefits. You were paid for the other service because it was 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 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 impacted tooth #18 (D7240) performed on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 22, 2021, billed with 
codes 81230, 81240, 81241, 81249, 81291, 81408 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 22, 2021, billed with codes 81230, 81240, 81241, 81249, 81291, 81408 and 81335.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and 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. 
 
The record shows you received the requested 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 pay for a limited oral evaluation (D0140) provided by an out-of-network provider on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295, 82465, 83721 and 
84478 billed for date of service January 12, 2022. 
 
You asked the Plan to pay for procedure codes 82435, 84132, 84295, 82465, 83721 and 84478. You say that 
these services are supported as billed. The Plan denied your request. The Plan says payment for these codes is 
bundled into payment for other codes which were billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
82435, 84132 and 84295 are each column II codes to column I code 80051. In addition, code 83721 is a 
column II code to column I code 80061. These services have not been billed with an appropriate modifier to 
bypass the edit. 
 
We have also confirmed that codes 82465 and 84478 are column II codes to column I code 80061. These code 
pairs each have a modifier indicator of 0. The column II codes are therefore not payable. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 82435, 84132, 84295, 82465, 83721 and 84478 billed for date of service January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460), an unspecified preventive 
procedure (D1999), and a diagnostic consultation service (D9310), provided by a participating provider on 
May 4, 2022. 
 
You asked the Plan to pay for pulp vitality tests, an unspecified preventive procedure, and a diagnostic 
consultation service. You say that you did not receive all these services. The Plan denied your request. The 
Plan says the rendered dental 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 pay for pulp vitality tests (D0460), an unspecified preventive procedure (D1999), and a diagnostic consultation service 
(D9310), provided by a participating provider on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery, or surgical bone reshaping of all four 
quadrants (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that the surgery is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage of osseous surgery has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers osseous 
surgery when the services are medically necessary and reasonable.  
 
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 osseous surgery. Our reviewer says that 
the requested service is not medically reasonable and necessary. Our physician reviewer found that the supplied 
documentation does not support the request for surgery in all four quadrants.  Our reviewer says the x-rays 
and periodontal charting do not provide adequate evidence of the need for 
periodontal surgery.  Furthermore, the need for scaling and root planing are not supported since the amount of 
bone loss is not significant and a diagnosis of periodontis is not confirmed. In order to assess the need for 
periodontal surgery to correct bone defects, periodontal scaling must be performed, however, our physician 
reviewer found that there is no record of such treatments. 
 
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 osseous surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve osseous surgery, or surgical bone reshaping of all four quadrants (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment on tooth #12 (D6056) and an 
implant supported crown on tooth #12 (D6065). 
 
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 prefabricated abutments (D6056) and an implant 
supported crown (D6065) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment on tooth #12 (D6056) and an implant supported crown on tooth #12 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each additional intraoral-periapical x-rays (D0230 x3) 
provided by a network provider on April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you would only have to pay $50 
for the dentist. You say you believe you should have some compensation for the cost of the specialist. 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 each additional intraoral-periapical x-rays (D0230 
x3) provided by a network provider on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921) provided on 
March 9, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigationper quadrant (D4921) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a removable unilateral partial denture for tooth #3 and 4 (D5284). 
 
You asked the Plan to pre-approve a removable denture. You say that the fracture or cap acts as a crevice and 
holds food particles between the teeth, which makes it hard to clean each time you eat anything. The Plan 
denied your request. The Plan says that this service is not medically necessary. 
 
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 removable 
denture when the services are medically necessary and reasonable. 
 
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 a removable denture. Our reviewer says 
that a removable partial denture is medically reasonable and necessary. Our physician reviewer found that the 
supplied x-rays reveal adequate bone support on the abutment teeth to allow for a removable appliance.  The 
location of the bridge in the upper right quadrant was noted on at least one of the claim forms submitted. Two 
teeth are the maximum number of teeth suitable for a flexible removable appliance. 
 
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 a removable denture have been met. Therefore, we decided that the Plan has to 
pre-approve a removable unilateral partial denture for tooth #3 and 4 (D5284).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup and crown porcelain (D2950, D2740) 
provided on April 12, 2022. 
 
You asked the Plan to pay for the core buildup and crown porcelain. 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 pay for a core 
buildup and crown porcelain (D2950, D2740) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) and a 
comprehensive oral evaluation (D0150), provided by a participating provider on March 18, 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 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 December 21, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) and a 
comprehensive oral evaluation (D0150), provided by a participating provider on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7210, D0140, D9613) provided on March 
14, 2022. 
 
You asked the Plan to pay for 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 dental services were received from an out-of-
network provider and 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 Plan's coverage rules apply in this case. 
 
The record shows you received the requested 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 pay for dental services (D7210, D0140, D9613) provided on March 14, 2022.