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

 
We decided that the Plan does not have to pre-approve the clinical crown lengthening on tooth #14. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because you 
need this service. 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 when the Plan approved this service for 
tooth #13 on the same authorization request. Therefore, we decided that the Plan does not have to pre-approve 
the clinical crown lengthening on tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 14, 2022. 
 
You asked the Plan to pay for a consultation. You say that you feel that the service was billed incorrectly. The 
Plan denied your request. The Plan says the service at issue 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 
consultation (D9310) provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for intraoral procedures provided on June 1, 2022. 
 
You asked the Plan to pay for anesthesia for intraoral procedures. The Plan denied your request. The Plan says 
under Medicare rules the request for these services is not a covered benefit. This request is related to dental 
procedures that are non-covered under Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for anesthesia for intraoral 
procedures provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete series of intraoral x-rays (D0210) and 
prophylaxis (D1110) provided on June 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were advised by the Plan, and given a 
list of dentists that showed this provider was in-network. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. The Plan also says that you were not advised to go to this dentist by the Plan 
representative you spoke with on April 19, 2022. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the complete series of intraoral x-rays 
(D0210) and prophylaxis (D1110) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewing 
radiographic images (D0274), and periodontal maintenance (D4910) provided on June 28, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewing 
radiographic images (D0274), and periodontal maintenance (D4910) provided on June 28, 2022, by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #28 (D7140) and the placement of an 
intra-socket biological dressing (D7922) provided on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 the extraction of tooth #28 (D7140) and the placement of an intra-socket biological dressing (D7922) 
provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 7, 2022. 
 
You asked the Plan to pay for a consultation. You say that you cannot afford to pay the charges. The Plan 
denied your request. The Plan says the service at issue 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 
consultation (D9310) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom abutments (D6057 x2), an abutment supported crown 
(D6058), and an abutment supported retainer (D6068) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. The 
Plan denied your request. The Plan says the services at issue 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 custom 
abutments (D6057 x2), an abutment supported crown (D6058), and an abutment supported retainer (D6068) 
provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from April 12, 2022, to May 31, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the provider assured you that they are in-
network. The Plan denied your request. The Plan says the dental services were either not covered under your 
dental plan or 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. Additionally, 2D oral/facial photographic image 
was denied separately as this service is not among those covered under your dental benefit.  Therefore, we 
decided that the Plan does not have to pay for the dental services provided from April 12, 2022, to May 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 11, 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 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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two endosteal implants (D6010 x2) and two bone 
replacement grafts for ridge preservation (D7953 x2) provided on February 10, 2022, and July 25, 2022. 
 
You asked the Plan to pay for the endosteal implants and bone replacement grafts. You say that you contacted 
the Plan in June, and were advised that you would have a 40% coinsurance for implants. You also say that you 
were charged over $3,000 because nothing but the extractions were covered. The Plan denied your request. The 
Plan says these services are not included on 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 pay for the two 
endosteal implants (D6010 x2) and two bone replacement grafts for ridge preservation (D7953 x2) provided on 
February 10, 2022, and July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal on tooth #4 (D3320) provided on July 14, 2022. 
 
You asked the Plan to pay for a root canal. You say that this service should be covered as it was medically 
necessary. The Plan denied your request. The Plan says the requested service is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a root canal on tooth #4 (D3320) 
provided on July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the records provided support the need 
for bone marrow aspirate. The Plan denied your request. The Plan says medical studies have not proven that 
bone marrow aspirate is helpful for treatment of the enrollee's health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of bone marrow aspiration in conjunction with the planned cervical 
spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
bone marrow aspirate for this enrollees medical condition as discussed above. Therefore, the requested bone 
marrow aspirate in the setting of C4-6 anterior cervical discectomy and fusion, in this case, is not medically 
reasonable or necessary.  
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on March 1, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you disagree with the denial of dental services. 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 January 20, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on March 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported crown (D6058) provided on June 9, 2022. 
 
You asked the Plan to pay for dental implants and related services. You say that you believe the Plan should be 
paying for some of this. The Plan denied your request. The Plan says the rendered dental services 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. 
 
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 custom 
fabricated abutment (D6057) and an abutment supported crown (D6058) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper denture (D5110) and the lower denture (D5120) 
provided on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for all of the bill and the 
dentist office changed the dates of service. The Plan denied your request. The Plan says your yearly dental 
benefit allowance has been exhausted. Also, the Plan confirmed with the dentist office that there was no charge 
for the prior date of service and the enrollee returned on May 23, 2022, to finish the rest of the dental 
procedures. 
 
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 yearly dental combined allowance of $1,500 was exhausted on the date of service of May 23, 2022. 
Therefore, we decided that the Plan does not have to pay for the upper denture (D5110) and the lower denture 
(D5120) provided on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator provided on January 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a home ventilator. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home ventilator provided on January 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient needed this care, and it should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray service provided on July 25, 2022. 
 
You asked the Plan to waive the copayment for an x-ray service. You say that you feel that the services should 
be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $10 copayment for an x-ray service. This item/service falls within the outpatient 
diagnostic tests/x-rays benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray 
service provided on July 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the abdomen and pelvis; 
with contrast material(s) (74177). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee had a CT scan of 
the abdomen and pelvis on March 30, 2016, which showed either focal nodular hyperplasia or hemangioma in 
the right lobe of the liver. A follow-up has been recommended. The enrollee now presents with vague 
abdominal pain. The physical exam revealed a possible small ventral hernia. No abnormal labs have been 
submitted. An ultrasound has not been provided. The enrollee is due for a colonoscopy in 2024. The medical 
necessity of the requested CT scan of the abdomen and pelvis has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the abdomen and pelvis; with contrast material(s) (74177).