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

 
We decided that the Plan does not have to pay for the reline complete maxillary denture (indirect) (D5750) 
May 16, 2022, to intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), and resin-based composite - one surface, anterior (D2330) May 17, 2022 
 
You asked the Plan to pay for the complete upper denture reline, first and additional periapical x-rays and 
filling. You say that you feel you are being asked to pay too much for these services. The Plan denied your 
request. The Plan says the cost-sharing has been applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the complete upper denture reline with 50% coinsurance, the first and additional periapical x-rays with a $15 copayment 
each and fillings with 20% coinsurance. Additionally, the comprehensive dental services are subject to a $100 
deductible. 
 
We looked at the file and Medicare rules. You have been asked to pay a $15 copayment for each periapical x-
ray. You have also been asked to pay your $100 deductible plus 20% coinsurance for the filling and 50% 
coinsurance for the complete upper denture reline. 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 for the reline 
complete maxillary denture (indirect) (D5750) May 16, 2022, to intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230), and resin-based composite - one 
surface, anterior (D2330) May 17, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve preventive resin fillings (D1352). 
 
You asked the Plan to pre-approve fillings. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that preventive resin fillings (D1352) are not covered the enrollee's dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
preventive resin fillings (D1352).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the deluxe frame (V2025) provided on April 13, 2022. 
 You asked the Plan to pay more for the deluxe frame. You say that you believe the billing and benefit coverage 
is wrong. The Plan denied your request. The Plan says your plan will not cover this amount because you have 
already received the maximum amount of coverage allowed for this type of service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to the annual $100 allowance offered every year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $100 for the deluxe frame 
(V2025) provided on April 13, 2022, and your eyewear allowance has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the and deluxe frame have not been met. 
Therefore, we decided that the Plan does not have to pay more for the deluxe frame (V2025) provided on April 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the surgical extraction (D7210) provided on March 4, 
2022. 
 
You asked the Plan to pay in full for the surgical extraction. You say that you should not have to pay for this 
service because of everything you went through. The Plan denied your request. The Plan says this claim was 
processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a $50 
deductible, plus a 20% coinsurance for the surgical extraction because it was rendered by an in-network 
provider. Therefore, we decided that the Plan does not have to pay in full for the surgical extraction (D7210) 
provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
7, 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 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 9, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 7, 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 (D6059) provided by an out-of-network provider on March 19, 2022. 
 
You asked the Plan to pay for a custom fabricated abutment and an abutment supported crown. You say that 
your Plan covers up to $2,000 for dental services. 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 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 (D6059) provided by an out-of-network 
provider on March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service February 18, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says the payment for this service is bundled into the 
payment for code G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally for tooth number one (D0350), and oral hygiene instructions for tooth number one (D1330) 
provided on May 18, 2022. 
 
You asked the Plan to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally for tooth 
number one (D0350), and oral hygiene instructions for tooth number one (D1330). You say that you say that 
your contract states that "with routine dental you get a $0 copayment on exams, routine cleanings, x-rays" from 
the Plan network. The Plan denied your request. The Plan says these services are not covered under 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, dental codes D0350 and D1330 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 2D 
oral/facial photographic image obtained intra-orally or extra-orally for tooth number one (D0350), and oral 
hygiene instructions for tooth number one (D1330) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this should be paid. 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 July 22, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete upper denture (D5110) provided on June 9, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware the provider was out-
of-network and you cannot afford to pay the charges. 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 complete upper denture (D5110) provided 
on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (D9222 and D9223) provided by a participating 
provider on May 24, 2021. 
 
You asked the Plan to pay for anesthesia. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered 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 pay for anesthesia 
(D9222 and D9223) provided by a participating provider on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction 
of tooth #20 (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and extraction. You say that you are still in a lot of pain. The 
Plan denied your request. The Plan says that the requested services are not covered when received by an oral 
surgeon. 
 
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 when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction of tooth #20 (D7210) 
provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364), pulp vitality tests (D0460), and limited oral evaluation - problem focused (D0140) 
provided June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary to make a 
knowledgeable plan for dental care. The Plan denied your request. The Plan says your benefit for the limited 
oral exam has already been exhausted. The remaining 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, certain limitations apply. The record 
shows your benefit for the limited oral exam was exhausted on date of service April 12, 2022. Your benefit 
does not include cone beam CT scans or pulp vitality tests as covered services. Therefore, we decided that the 
Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), 
pulp vitality tests (D0460), and limited oral evaluation - problem focused (D0140) provided June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and repair broken 
complete denture base, maxillary (D5512) provided on August 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel that the old dentures done on the 
appealed claim should be voided so that the new ones do not get denied due to frequency limitations. 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 August 19, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and 
repair broken complete denture base, maxillary (D5512) provided on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you believe this procedure is medically 
necessary, and is not excluded from the benefit policy. The Plan denied your request. The Plan says this service 
is not covered under the enrollee's benefit package. 
 
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 two 
endosteal implants (D6010 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services (80061, 82306, 83036, 84439, 
84443, 84480 and 86703) provided on March 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says that there is insufficient documentation to support the 
medical necessity of these services, and some codes were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that tests not ordered by the physician who is treating the 
beneficiary are not reasonable and necessary. The rules also say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory testing have been met. 
Specifically, the medical records do not include a signed physician order or test requisition form. No progress 
notes or records from prior to testing were submitted to support medical necessity or an intent to perform the 
tests at issue. In addition, we have confirmed that code 84480 is a column II code to column I code 84481 with 
a modifier indicator of 0. The column II code is therefore not payable. Therefore, we decided that the Plan does 
not have to pay for laboratory testing services (80061, 82306, 83036, 84439, 84443, 84480 and 86703) 
provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7140) provided by a participating 
provider on April 22, 2022. 
 
You asked the Plan to pay for a tooth extraction. You say that you would like the Plan to pay for a portion of 
this bill. The Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a tooth 
extraction (D7140) provided by a participating provider on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), multiple organisms; amplified probe(s) technique (87801). 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the decision and request 
reconsideration of the claim due to codes being deemed experimental and investigation and not medically 
necessary 
 The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. Laboratory testing is 
not a Medicare benefit when done without documentation of medical indication from the treating provider. 
 
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 87801 is Infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory services. Our reviewer says that the records do 
not meet the Medicare criteria for coverage of the laboratory services. Our reviewer found the medical 
documentation does not clearly document the appropriate description to indicate the use of code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; 
amplified probe(s) technique (87801).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim to be paid. 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 August 18, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards. 
 
You asked the Plan to pre-approve side guards. The Plan denied your request. The Plan says side guards do not 
primarily serve a medical purpose. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve side guards.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded as 81162, 81201, 81292, 81295, 
81298, 81314, 81317, 81321, 81334, 81351 and 81479 provided April 27, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are requesting a re-determination of the 
denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan says 
does not meet Medicare NCD/LCD criteria. The provider did not bill as required by Medicare coding 
regulations.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Plan confirmed with outreach with the referring/ordering 
provider listed on the claim and was advised that the doctor did not order the genetic testing for the enrollee. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing coded as 81162, 81201, 
81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351 and 81479 provided April 27, 2022.