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

 
We decided that the Plan does not have to pay an additional amount for the core build up (D2950), root canal 
(D3310), extraction (D7140), crown (D2740), retainer crowns (D6740 x 3), pontic (D6245 x 2), limited oral 
evaluation (D0140), prophylaxis (D1110), and periapical x-ray (D0220 x 2) provided from February 4, 2021, to 
November 15, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the services were 
previously approved. You also say that you would like the plan to pay for these services. The Plan denied your 
request. The Plan says the cost share amounts were applied correctly. The Plan also says that after the annual 
maximum is exhausted, any remaining charges are your 
responsibility. 
 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 the services are listed as covered, 
the cost share amounts still apply. This is a contractual obligation you agreed to when you enrolled in the 
Plans dental coverage. Additionally, the record shows that the annual maximum benefit of $1,000 has been 
exhausted. The record shows that the Plan paid $49 for services received on February 4, 2021, $187.50 for 
services received on February 8, 2021, $49 for services received on February 18, 2021, $47 for services 
received on March 8, 2021, $27.50 for services received on March 11, 2021, $254.50 for services received on 
March 19, 2021, and $385.50 for services received on April 9, 2021. $49 + $187.50 + $49 + $47 + $27.50 + 
$254.50 + $385.50 = $1,000. Therefore, we decided that the Plan does not have to pay an additional amount for 
the core build up (D2950), root canal (D3310), extraction (D7140), crown (D2740), retainer crowns (D6740 x 
3), pontic (D6245 x 2), limited oral evaluation (D0140), prophylaxis (D1110), and periapical x-ray (D0220 x 2) 
provided from February 4, 2021, to November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 11, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70498. 
 
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 70450 
is a column II code to column I code 70498. 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 procedure code 70450 billed for date of service August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service May 4, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were billed correctly. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) billed for 
date of service May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), resin-
based composite - one surface, anterior (D2330), resin-based composite - four or more surfaces or involving 
incisal angle (anterior) (D2335), resin-based composite - one surface, posterior (D2391), and limited oral 
evaluation - problem focused (D0140) provided on July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that if you had known the bill would be for $738 
you would have passed on three of the filling replacements. You say that you would have only gotten the one 
you had originally planned on. 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 resin-based composite - one surface, anterior (D2330), resin-based composite - four 
or more surfaces or involving incisal angle (anterior) (D2335), and resin-based composite - one surface, 
posterior (D2391) was exhausted on dates of service April 22, 2022 and July 22, 2022. Additionally, the Plans 
dental benefits do not include coverage for the limited oral evaluation - problem focused (D0140). 
 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image 
(D0220), resin-based composite - one surface, anterior (D2330), resin-based composite - four or more surfaces 
or involving incisal angle (anterior) (D2335), resin-based composite - one surface, posterior (D2391), and 
limited oral evaluation  problem focused (D0140) provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was a quick phone call to get 
results and you shouldnt be charged for this. 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 Office visits. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the Office visits 
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 office visit provided on June 07, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the notes do not 
mention trial and failure of at least 3 months of non-pharmacologic therapy and simple analgesics. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
does not indicate that the enrollee has not responded to conservative non-pharmacologic therapy or to simple 
analgesics, such as acetaminophen. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. Our reviewer found that the Medicare approved drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), and an implant 
supported crown (D6065) provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and an implant supported crown. You say that you 
need these services. The Plan denied your request. The Plan says the requested dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056), and an implant supported crown (D6065) provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior resin-based composite one surface, posterior 
resin-based composite two surfaces and inhalation of nitrous oxide provided on May 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider failed to follow up and let this go 
unpaid. The Plan denied your request. The Plan says this claim was received after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until August 19, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the posterior resin-based composite one surface, posterior resin-based 
composite two surfaces and inhalation of nitrous oxide provided on May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on July 19, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 99291 is not supported in the medical record. Specifically, no critical care note was 
provided. Based on this information, we decided that Medicare rules for coverage of the critical care services 
have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) 
provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) and an abutment 
supported porcelain fused to metal crown (D6059) for tooth #14 provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that when you changed coverages, you thought that 
crowns were covered and did not know there were various types of crowns. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the prefabricated abutment and the 
abutment supported porcelain fused to metal crown are not covered by the 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 a 
prefabricated abutment (D6056) and an abutment supported porcelain fused to metal crown (D6059) for tooth 
#14 provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency oral evaluation (D0140) provided on June 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and the dental services 
provided were an emergency. 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 the date of service of February 24, 2022. 
Therefore, we decided that the Plan does not have to pay for an emergency oral evaluation (D0140) provided 
on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260) provided by a participating 
provider. 
 
You asked the Plan to pre-approve osseous surgery. You say that you need these services. The Plan denied 
your request. The Plan says the requested 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 pre-approve 
osseous surgery (D4260) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits (99213, 99214) provided from 
November 30, 2021 to December 28, 2021. 
 
You asked the Plan to waive the copayment for the office visits. You say that the services should be covered as 
you disagree with the denial. 
 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 Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $30 copayment for three office visits. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 office visits (99213, 99214) provided from November 30, 2021 to December 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0150), a radiographic image 
(D0330), a complete upper denture (D5110), and a complete lower denture (D5120) for tooth #10 and #18 
provided on June 2, 2022, and June 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you had no choice but to see the out-of-
network dentist and did not know that the bill was going to be so high. 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 an oral evaluation (D0150), a radiographic 
image (D0330), a complete upper denture (D5110), and a complete lower denture (D5120) for tooth #10 and 
#18 provided on June 2, 2022, and June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service 
because it is medically necessary. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the clinical crown lengthening is not covered by the 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 the 
clinical crown lengthening (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the examination was necessary for the dentist to 
do before a root canal, and you would like the Plan to pay for it. 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 May 31, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for adult prophylaxis (D1110), bitewings (D0274) and a 
comprehensive oral evaluation (D0150) provided on May 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the brochure, which you received from the 
Plan for 2022 dental coverage states that services are covered in full at in-network providers up to the annual 
maximum. You also say that you should not be billed for any of these procedures. 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 adult prophylaxis (D1110), bitewings 
(D0274) and a comprehensive oral evaluation (D0150) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture repair provided on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you could not help that your dentures broke. 
You say you did not know about the 36-month limit. 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 February 9, 2022. 
Therefore, we decided that the Plan does not have to pay for the denture repair provided on June 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 13, 2022, to May 12, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from April 13, 2022, to May 12, 
2022.