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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), crown (D2751), core buildup, including any pins when required (D2950), 
and four periodontal scalings and root planings (D4341 x4) provided on December 7, 2021, and December 16, 
2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 
crown, core buildup, and scalings and planings. You say that you asked the provider how much the services 
would cost, and you were told they would be covered. You also say that if you had known your insurance 
would not cover these procedures, you would not have had these services. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says that neither you 
nor the provider contacted the Plan prior to the dates of service to verify benefits and provider eligibility.  
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 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), crown (D2751), core 
buildup, including any pins when required (D2950), and four periodontal scalings and root planings (D4341 
x4) provided on December 7, 2021, and December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210, D7250) provided on 
February 12, 2021. 
 
You asked the Plan to pay for the extractions. You say that it was medically necessary to have these teeth 
removed following your cancer treatment, and you feel these services should be covered in full as they were 
related to your medical treatment. The Plan denied your request. The Plan says they have agreed to reprocess 
the covered extractions at the in-network rate; however, your benefit covers a maximum of two extractions per 
calendar year. The additional extractions exceed this frequency limitation and remain denied. 
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 can cover two 
extractions per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extractions are requested in a 
frequency that is not covered under this benefit. Although these services may have been necessary as a result of 
medical treatment, they were not necessary in order to perform medical treatment. When you have teeth 
extracted because the teeth themselves are breaking and in poor condition, the services are considered dental in 
nature. Your dental benefit covers a maximum of two extractions per year, and the documentation shows that 
the Plan covered two of the extractions provided on this date. Therefore, we decided that the Plan does not have 
to pay for the additional surgical extractions (D7210, D7250) provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on December 13, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
you needed to change dentists. The Plan denied your request. The Plan says these services exceed the 
frequency limitations in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year, and you are limited to one panoramic x-ray 
(D0330) every three plan years. The record shows that you received a problem focused limited oral evaluation 
(D0140) and panoramic x-ray (D0330) on November 3, 2021 and your problem focused limited oral evaluation 
(D0140) and panoramic x-ray (D0330) benefits have been exhausted. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) 
provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910 x 2) provided from 
April 7, 2021, to August 11, 2021, by an opt out provider. 
You asked the Plan to pay for the dental services. You say that you opted out of Medicare in 2007. You say 
that you are now receiving notification that your patient's reimbursements are being negatively affected. You 
also say that an exception should be made. The Plan denied your request. The Plan says payment cannot be 
made to a provider that has opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the periodontal maintenance (D4910 x 2) provided from April 7, 2021, to 
August 11, 2021, by an opt out provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided September 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. This test is non-covered under Medicare. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 1, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you thought the consultation 
(not a general oral exam) would be covered under your insurance policy. The Plan denied your request. The 
Plan says this service has exceeded the frequency limitation within a calendar year. 
 
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, oral exams are limited to up to 2 every 
calendar year; either D0120, D0150 or D0180. The record shows that you received exams on March 23, 2021, 
and May 4, 2021 and your oral exams benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on November 30, 2021. 
 
You asked the Plan to pay for the crown. You say that the crown replacement should have been covered. The 
Plan denied your request. The Plan says this service is not a covered expense under your 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 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 crown 
(D2750) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the filling (D2392) provided on 
December 14, 2021. 
 
You asked the Plan to pay the in network rate for the filling. You say that there were no in network providers in 
your area. You also say that the root canal should be paid at 100%. The Plan denied your request. The Plan 
says no additional payment will be made for the filling. 
 
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 2 fillings are covered per calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received 
on March 18, 2021. Therefore, we decided that the Plan does not have to pay the in network rate for the filling 
(D2392) provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided September 20, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule this code has a status of "B" and is always bundled with another service. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided September 
20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the The Life2000 System portable ventilator. 
 
You asked the Plan to pre-approve the The Life2000 System. You say that you would like reconsideration 
because the requested equipment is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 The Life2000 System. Our reviewer 
says that this device provides positive pressure oxygen via nasal cannula during activity.  It is not a true 
ventilator because it cannot provide sufficient flow rates for full ventilatory support.  It has not been 
convincingly shown to be effective in the treatment of COPD.  Our physician reviewer found further, this enrollee does not meet Medicare criteria for a home ventilator.  
There is no evidence of CO2 retention or failure of bipap treatment. 
 
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 The Life2000 System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the The Life2000 System portable ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and surgical extraction (D7210). 
 
You asked the Plan to pre-approve the crown and extraction. The Plan denied your request. The Plan says these 
services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and surgical extraction (D7210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 83970) provided July 7, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. Payment for these lab services is included in payment for the ESRD 
facility services. The codes billed are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (82728, 83540, 83550, 83970) provided July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
8, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the treating provider was advised to 
opt out of Medicare because they had no interaction with Medicare at all since the practice was started in 2007. 
You also say that if you had been informed that it would have affected dental reimbursements for the patients, 
the provider would have reconsidered the choice to opt out. The Plan denied your request. The Plan says this 
service was rendered by a provider who chose not to receive Medicare funds. The Plan also says that the 
treating provider opted out of Medicare effective November 17, 2016, to November 17, 2022. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on December 8, 2021 by a 
Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia (D9222, D9223 x 2), and drug 
injection (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has an abscess. You say that 
the local sedation would not work for the enrollee for this procedure. You also say that the deep sedation is 
medically necessary. The Plan denied your request. The Plan says general anesthesia services are not covered. 
The Plan says that drug injection is not covered either. 
 
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 general anesthesia 
services and drug injection are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve general anesthesia (D9222, D9223 x 2), and drug injection (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on November 16, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the contract does not 
state that the second cleaning has to be 6 months to the date from the previous cleaning. The Plan denied your 
request. The Plan says these services are only allowed once every six months. 
 
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, oral exams and cleanings are each 
limited to 1 every 6 months. The record shows that you received a periodic oral evaluation (D0120) and 
prophylaxis (D1110) on May 26, 2021 and your oral exams and cleanings benefits had been exhausted through 
November 26, 2021. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two intravenous moderate (conscious) sedation/analgesia 
services (D9243 x2) provided on December 11, 2021. 
 
You asked the Plan to pay for the intravenous moderate (conscious) sedation/analgesia services. You say that 
you feel that you should not be responsible for this charge. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
intravenous moderate (conscious) sedation/analgesia services (D9243 x2) provided on December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the ongoing rental of the Autoserver Ventilator (E0471). 
 
You asked the Plan to pre-approve the ongoing rental of the Autoserver Ventilator. You say that you would like 
reconsideration because this equipment is necessary for your health and well being. The Plan denied your 
request. The Plan says that this request does not meet medical necessity criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the ongoing rental of the Autoserver 
Ventilator. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found you have met the minimum usage requirement from late 
January onward. The followup visit indicates good compliance over the previous month. Your appeal letter 
describes symptomatic improvement with recent consistent use.  Given the recent improved use, it is 
reasonable to extend coverage for 3 months and to re-evaluate compliance at that time. 
 
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 ongoing rental of the Autoserver Ventilator have been met. Therefore, we 
decided that the Plan has to pre-approve the ongoing rental of the Autoserver Ventilator (E0471).  
 
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 limited oral evaluation (D0140), periapical radiographic 
imaging (D0220), tooth extraction (D7140), and biological dressing (D7922), provided by a participating 
provider on November 30, 2021, to December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that you feel like this was incorrectly denied. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic imaging (D0220), tooth extraction (D7140), and biological dressing (D7922), provided by a participating provider on November 30, 2021, to December 2, 2021.