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

 
We decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210) 
provided on February 2, 2022. 
 
You asked the Plan to pay the in network rate for the complete series x-ray. You say that you should not have 
to pay anything. The Plan denied your request. The Plan says complete series x-ray is not listed as 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, the complete series x-ray is 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 complete series x-ray (D0210) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on January 11, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were not aware the 
dentist was not in network. You say that you feel comfortable with this dentist. You say that you would prefer 
to stay with this dentist instead of going to a dentist you are not comfortable with. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
out of network dentists may bill you for any amount greater than what the plan pays the provider. Additionally, 
the frequency limit of 1 panoramic x-ray or complete series x-ray every 5 calendar years has been exceeded. 
The record shows that the Plan paid for a complete series x-ray that you received on July 2, 2020. Therefore, 
we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning provided on April 9, 2021, and the 
discharge day management provided on April 14, 2021, billed with codes 99497 and 99239, respectively. 
 
You asked the Plan to pay for the physician services as billed. You say that the records support the billed 
services. The Plan denied your request. The Plan says codes 99497 and 99239 remain unsupported by the 
submitted records. 
 
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 99497 is Advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. The definition of code 99239 is Hospital discharge day 
management; more than 30 minutes.  
 
We find that CPT code 99497 is not supported in the medical record. Specifically, the progress note from April 
9, 2021, does not include any documentation of time spent with advance care planning. CPT code 99239 is also 
not supported because the note does not document that 31 or more minutes were spent providing care. Based on 
this information, we decided that Medicare rules for coverage of the physician services as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the advance care planning provided on April 
9, 2021, and the discharge day management provided on April 14, 2021, billed with codes 99497 and 99239, 
respectively.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on December 1, 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 95886 and 95910 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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The definition of code 95910 is nerve conduction studies; 
7-8 studies. 
 
We find that CPT code 95886 and 95910 are not supported in the medical record. Specifically, there is no 
documentation of a complete needle electromyography to support code 95886. There is no documentation of 7-
8 nerve conduction studies to support code 95910. 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 testing services rendered on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment simulation using 3D image volume (D0393) 
provided August 31, 2021. 
 
You asked the Plan to pay for the treatment simulation. You say that this was a necessary service that should be 
covered under your dental or medical benefits. The Plan denied your request. The Plan says this service is not 
covered under your dental or medical 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 the 
treatment simulation using 3D image volume (D0393) provided August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling and debridement (D6081), surgical removal of 
implant (D6100), bone replacement graft (D7953), and a guided tissue regeneration (D4266) provided by an 
out-of-network provider on December 15, 2021. 
 
You asked the Plan to pay for scaling and debridement, surgical removal of implant, bone replacement graft, 
and a guided tissue regeneration. You say that you needed these services because you had severe tooth pain. 
The Plan denied your request. The Plan says the dental benefits that were provided 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 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 scaling and 
debridement (D6081), surgical removal of implant (D6100), bone replacement graft (D7953), and a guided 
tissue regeneration (D4266) provided by an out-of-network provider on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245), and porcelain for resin bonded fixed 
prosthesis retainer (D6548 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for this bridge if it 
is not authorized. You say that you bought this policy specifically because of the dental coverage. You also say 
that you do not understand why this is not covered. The Plan denied your request. The Plan says the pontic and 
porcelain for resin bonded fixed prosthesis retainer are not listed as covered 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, the requested pontic and retainer crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve a pontic (D6245), and porcelain for resin bonded fixed prosthesis retainer (D6548 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065) to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve an implant supported crown. You say that you need these services done. 
You say that you need to complete the dental process you have been receiving. The Plan denied your request. 
The Plan says D6065 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 an 
implant supported crown (D6065) to be provided by a participating provider.
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 
December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that not having this paid for is causing a hardship for 
you. The Plan denied your request. The Plan says services provided out-of-network 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. The Plan covers covered 
dental services when provided by a participating provider. 
 
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 a participating provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on January 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist for a new clasp for your 
partial. You say that you saw the dentist for 5 minutes and left. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation and 
panoramic x-ray are listed as covered, the frequency limits have been exceeded. The record shows that 1 
comprehensive oral evaluation is covered every 3 years and 1 panoramic x-ray is covered every 5 calendar 
years. The record also shows that the Plan paid for these services you received on January 11, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-
ray (D0330) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on January 5, 2022. 
 
You asked the Plan to pay for the preventive procedure. You say that you were not advised that this treating 
provider was out-of-network. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to 
verify 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 the 
preventive procedure (D1999) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture for 
edentulous arch (D6111) to be provided by a participating provider. 
 
You asked the Plan to pre-approve implant /abutment supported removable denture for edentulous arch. You 
say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the 
requested dental 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 pre-approve 
implant /abutment supported removable denture for edentulous arch (D6111) to be provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported retainer (D6068) and pontic (D6245) 
provided on December 7, 2021. 
 
You asked the Plan to pay for the abutment supported retainer (D6068) and pontic (D6245). You say that you 
needed a cap and bridge where they pulled the tooth. You say that you were told they would cover 50%. The 
Plan denied your request. The Plan says the 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 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 
abutment supported retainer (D6068) and pontic (D6245) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider on December 13, 2021, to December 22, 2021. 
 
You asked the Plan to pre-approve a complete maxillary and mandibular denture. You say that this dental work 
is medically necessary. The Plan denied your request. The Plan says D5110 and D5120 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 a 
complete maxillary and mandibular denture (D5110 and D5120) provided by a participating provider on 
December 13, 2021, to December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided January 4, 2022. 
 
You asked the Plan to pay for the limited oral exam and periapical x-ray. You say that your plan booklet states 
that exams and x-rays are covered. The Plan denied your request. The Plan says these services are 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 pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
provided January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal procedure (D4999) and inhalation of nitrous 
oxide/analgesia (D9230) provided on January 25, 2022. 
 
You asked the Plan to pay for the periodontal procedure and inhalation of nitrous oxide/analgesia. You say that 
these services were necessary to keep you calm. The Plan denied your request. The Plan says these services are 
not included in the benefits section of your Evidence of Coverage. 
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 
periodontal procedure (D4999) and inhalation of nitrous oxide/analgesia (D9230) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate partial lower denture with resin base (D5222) 
provided on December 13, 2021. 
 
You asked the Plan to pay for the dental item. You say that your provider advised you should use the remainder 
of your $2,000 benefit before the end of the year. You also say that you feel additional payment should be 
made. 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit of $1,000 
has been exhausted. The record shows that the Plan paid $160 for services received on November 11, 2021, and 
$840 for services received on December 13, 2021. $160 + $840 = $1,000. Therefore, we decided that the Plan 
does not have to pay for the immediate partial lower denture with resin base (D5222) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve a crown. You say that you are hoping for a one-time exception to increase 
your dental maximum allowance amount. You say that you need these services done. The Plan denied your 
request. The Plan says the dental maximum allowance amount has 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 Plan's coverage rules apply in this case. The Plan covers up to a $2,500 
dental maximum for combined in-network and out-of-network services per calendar year. 
 
We looked at the file and Medicare rules. The maximum dental allowance has already been met. Based on this 
information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a crown (D2740) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845), endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848), and endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase, includes electronic sensor(s), any type (L5856). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the request for a microprocessor K3 functional level knee component does not meet 
Medicare criteria as reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the items. Our physician reviewer 
found there is no documentation that meet all of the requirements listed in the LCD: Lower Limb Prostheses 
(L33787) and the Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to 
DME MACs (A55426) for Medicare coverage of the requested microprocessor K3 functional level knee 
component. Provided medical records do not clearly define why the microprocessor knee is medically required 
as opposed to a K3 level mechanical knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code 
L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), endoskeletal knee-shin 
system, fluid stance extension, dampening feature, with or without adjustability (L5848), and endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of blood (D7921), and 
drug injections (D9612) to be provided by a participating provider. 
 
You asked the Plan to pre-approve the collection and application of blood and drug injections. You say that the 
dentist will not perform these services without medication. The Plan denied your request. The Plan says D7921 
and D9612 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 pre-approve the collection and application of blood 
(D7921), and drug injections (D9612) to be provided by a participating provider.