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

 
We decided that the Plan has to pre-approve reline complete upper denture (D5750). 
 
You asked the Plan to pre-approve the dental service. You say that your denture is 6 years old. You also say 
that you need this service. The Plan denied your request. The Plan says that denture relines, and adjustments 
are included with the denture benefit when performed within six months of denture placement. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan documents indicate that this service is covered once every 
36 months after 6 months have elapsed since the initial placement of the denture. There is no documentation 
provided that indicates you received an upper denture within 6 months of the request. Therefore, we decided 
that the Plan has to pre-approve reline complete upper denture (D5750).  
 
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 dental services provided by an out-of-network provider on 
October 6, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. 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 Plans coverage rules apply in this case. The Plan covers dental 
services when the services are provided by an out-of-network provider. 
 
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 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 on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from March 17, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services at issue are 
medically necessary. The Plan denied your request. The Plan says that 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 hospital services. 
Our reviewer says that the enrollee meets the criteria for acute inpatient mental health treatment beyond the 
date in question of March 17, 2022, forward. Our physician reviewer found although the enrollee was not 
shown to be a danger to herself or others, she was found be delusional with racing thoughts, hyperverbal 
communication and paranoid. She was not showing any auditory or visual hallucinations but was noncompliant 
with treatment. It did appear that the services were reasonably expected to improve the enrollees condition or 
for the purpose of diagnosis beyond the date in question. 
 
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 hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric care from March 17, 2022, forward.  
   
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 bone grafting (D7953) provided by a participating provider 
on October 28, 2021. 
 
You asked the Plan to pay for dental services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the rendered dental work 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 pay for a bone 
grafting (D7953) provided by a participating provider on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that you had the 
enhanced dental coverage under your plan. You say that you did not know that there was a limitation on the 
services. You say that you feel an exception should be made. You also say that it will be difficult for you to pay 
this bill. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 and oral exams and prophylaxis are 
covered twice per year, the frequency limit has been exceeded. The record shows that the Plan paid for an oral 
exam and prophylaxis that you received on January 20, 2021, and April 7, 2021. Therefore, we decided that the 
Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for somatosensory testing billed for services provided on March 11, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient documentation to corroborate the services. 
 
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 95927 is Short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the 
trunk or head. We find that CPT code 95927 is not supported in the medical record. Specifically, the records 
provided do not show that the billed service was provided to the enrollee on the date of service at issue. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for somatosensory testing billed for services provided 
on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on November 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have 2 policies. You also say that you feel 
this service should be covered under the dental policy. The Plan denied your request. The Plan says crown is 
not covered under the Medicare dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on 
November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported crowns (D6058) provided by a 
participating provider on July 28, 2021. 
 
You asked the Plan to pay for abutment supported crowns. You say that you fell and hit your head on a steel 
pipe. You say that you had to go to the dentist to fix your teeth. The Plan denied your request. The Plan says 
D6058 is not a covered dental 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 pay for abutment 
supported crowns (D6058) provided by a participating provider on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350) provided on November 22, 2021. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you feel this service should 
be covered as a one-time request by your endocrinologist. 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 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 two 
dimensional (2D) oral/facial photographic image (D0350) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the retainer crowns (D6750 x 2), pontic 
(D6240), and periapical x-rays (D0220, D0230) provided from March 6, 2021, to March 13, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the dental office advised 
they were in network with your insurance. You say that your insurance advised the provider was not in 
network. You say that the crown you received needs to be redone. You also say that these services should be 
covered in full or at least partially. The Plan denied your request. The Plan says the claim was processed 
correctly. 
 
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 and 1 periapical x-ray is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that 
you received on March 6, 2021. Additionally, the retainer crowns and pontic are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the 
retainer crowns (D6750 x 2), pontic (D6240), and periapical x-rays (D0220, D0230) provided from March 6, 
2021, to March 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with 
interpretation (D0365) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that you should not be responsible for this bill. The 
Plan denied your request. The Plan says the claim processed 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 cone beam CT capture with 
interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the cone beam computed tomography (CT) capture with interpretation (D0365) provided on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470), prosthodontic procedure 
(D5899), and a complete maxillary denture (D5110) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve diagnostic casts, prosthodontic procedure, and a complete maxillary 
denture. You say that you would like the Plan to approve this dental work and denture. The Plan denied your 
request. The Plan says D0470 and D5899 are not covered benefits. The plan says that D5110 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 Plan's coverage rules apply in this case. The Plan covers a complete maxillary denture once every five years. Diagnostic casts and prosthodontic procedure are not covered dental benefits. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D5110 was provided on March 
16, 2021. Based on this information, we decided that the Plan's rules for coverage of a complete maxillary 
denture have already been met. Diagnostic casts and prosthodontic procedure are not covered dental benefits. 
Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (D0470), prosthodontic 
procedure (D5899), and a complete maxillary denture (D5110) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit kit. 
 
You asked the Plan to pre-approve transit kit. The Plan denied your request. The Plan says the item is not a 
covered benefit. 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The item at issue in this appeal is for use outside of the home. Although this 
item may be helpful, neither Medicare nor the Plan covers this equipment. The item at issue in this appeal does 
not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to 
pre-approve transit kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 additional units of the services coded 15734 provided on 
October 12, 2020. 
 
You asked the Plan to pay for 2 additional units of the services. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says payment for 2 
additional units of CPT code 15734 cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 2 additional units of the services Our reviewer says that the 
documentation does not support payment for the additional units of service. Our reviewer found that the 
operative report does not support 2 additional flaps; trunk were performed and therefore cannot be verified. After careful review of the operative report documentation was not found to support additional units for this 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional units of the services have not been met. Therefore, we decided that 
the Plan does not have to pay for 2 additional units of the services coded 15734 provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320), crown (D2750), and core 
buildup, including any pins when required (D2950) provided from July 8, 2021, to August 31, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the endodontic therapy, crown, and core buildup. You say that you feel the 
amounts that were charged for these services were low. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says that you are responsible for a 50% coinsurance 
of the covered plan allowance after the $100 annual deductible is met, and you can be balance billed for the 
difference between what was billed and what was paid because the treating provider is not an in-network 
provider. 
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 responsible for a 50% 
coinsurance of the covered plan allowance after the $100 annual deductible is met, plus the difference between 
the billed amount and allowed amount because these services were received OON. Therefore, we decided that 
the Plan does not have to pay for the endodontic therapy (D3320), crown (D2750), and core buildup, including 
any pins when required (D2950) provided from July 8, 2021, to August 31, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on 
October 14, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you had a cap put on your 
tooth. You say that you were advised it would cost you $914. You say that you received a bill for an additional 
$704. You also say that you should not have to pay the full amount. The Plan denied your request. The Plan 
says the claim was processed correctly. 
 
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 and crown is listed as covered, there is 
a 50% coinsurance of the plan allowance after the $100 annual deductible is met. The record shows that the 
Plan's allowed amount for a crown is $452.50.  The Plan applied the remaining amount of the $100 deductible, $33. $452 - $33 = $419.50. $419.50 x 50% coinsurance = $209.75. Additionally, out of network providers may bill you for any amount greater than what the Plan pays the provider. Therefore, we decided that the Plan does not have to pay an additional amount for 
the crown (D2740) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 
22, 2021. 
 
You asked the Plan to pay for the dental service. You say that you told the provider to not do anything that your 
insurance would not cover. You say that you do not have money to pay for the services. You also say that you 
were not told that your insurance did not cover the x-ray. The Plan denied your request. The Plan says the 
frequency limit has been exceeded. 
 
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 and 1 complete series x-ray is covered 
every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a complete 
series x-ray that you received on November 8, 2019, less than 3 years ago. Therefore, we decided that the Plan 
does not have to pay for the complete series x-ray (D0210) provided on September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on October 24, 2021. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding 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. In this case, we have confirmed that code 76770 
is a column II code to column I code 93976. 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 ultrasound services coded 76770 provided on October 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on October 28, 2021. 
 
You asked the Plan to pay for intraoral imaging. You say that you do not understand why this is being denied. 
The Plan denied your request. The Plan says D0220 and D0230 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 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 intraoral 
imaging (D0220 and D0230) provided by a participating provider on October 28, 2021.