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

 
We decided that the Plan does not have to pay for prefabricated abutment on tooth #30 (D6056) and an implant 
supported crown on tooth #30 (D6066) provided on March 15, 2022. 
 
You asked the Plan to pay for prefabricated abutment and implant supported crown. You say that you disagree 
with the denial for dental services. The Plan denied your request. The Plan says prefabricated abutment 
(D6056) and an implant supported crown (D6066) are not covered by your 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 pay for 
prefabricated abutment on tooth #30 (D6056) and an implant supported crown on tooth #30 (D6066) provided 
on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (dental code D0140), the guided tissue 
regeneration (dental code D4266), and the bone replacement (dental code D7953) for tooth #19 provided on 
September 21, 2021. 
 
You asked the Plan to pay for the oral evaluation, the guided tissue regeneration, and the bone replacement. 
You say that the denied services were necessary. The Plan denied your request. The Plan says these services 
are not covered by the Plan'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 pay for the oral 
evaluation (dental code D0140), the guided tissue regeneration (dental code D4266), and the bone replacement 
(dental code D7953) for tooth #19 provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs dispensed for home use (D9630) and gingival 
irrigation (D4921 x 4) provided on February 8, 2021. 
 
You asked the Plan to pay for drugs and gingival irrigation. You say that you disagree with the denial for dental 
services. The Plan denied your request. The Plan says drugs dispensed for home use (D9630) and gingival 
irrigation (D4921) are not covered by your 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 pay for drugs 
dispensed for home use (D9630) and gingival irrigation (D4921 x 4) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for first radiographic image (dental code D0220) and additional 
radiographic image (dental code D0230) provided on February 23, 2022. 
 
You asked the Plan to pay for the radiographic images. You say that the dentist coded the claim wrong, and 
you believe it should be different. The Plan denied your request. The Plan says they confirmed with the 
provider and the claim was coded properly; therefore, the services are not covered by the Plan'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 pay for first 
radiographic image (dental code D0220) and additional radiographic image (dental code D0230) provided on 
February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for prophylaxis (D1110) provided on March 1, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that you have diabetes and needed to see an oral surgeon. 
The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records to show why replacing code D4910 
with code D1110 for a cleaning was appropriate. Without the medical records we are unable to determine if the 
cost sharing amount is correct. Therefore, we decided that the Plan has to pay for prophylaxis (D1110) 
provided on March 1, 2022.  
 
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 consultation (D9310) provided on January 25, 2022. 
 
You asked the Plan to pay for consultation (D9310). You say that you are on a fixed income and cannot afford 
to pay this bill. The Plan denied your request. The Plan says this service is not covered under your 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 consultation (D9310) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
consultation (D9310) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided by a 
network provider on February 14, 2022. 
 
You asked the Plan to pay for the unspecified adjunctive procedure (D9999). You say that you do not agree 
with the amount you were reimbursed by the Plan. You say the dentist indicated that they did not have a 
contract with the Plan. The Plan denied your request. The Plan says the service was 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 unspecified adjunctive procedure 
(D9999) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the unspecified adjunctive procedure (D9999) provided by a network provider on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tire (CPT code E2211 x2), insert 
for pneumatic propulsion tire (removable), any type, any size (CPT code E2213 x2), and axles: quick release 
(CPT code K0108 x2). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
There is a request for a K0108 Axles: Quick Release accessory. This does not serve a primary medical purpose. 
This is a convenience item. This is not covered as it is not reasonable and necessary per Medicare criteria. 
Furthermore, for CPT code(s): E2211 and E2213: Manual wheelchairs already come with standard tires, flat-
free tires. These are considered duplicate requests and therefore, not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic propulsion tire (CPT code E2211 x2), insert for 
pneumatic propulsion tire (removable), any type, any size (CPT code E2213 x2), and axles: quick release (CPT 
code K0108 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393) provided on March 24, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2393) provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided with 
drug testing on January 26, 2022, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this is medically 
necessary drug testing. The Plan denied your request. The Plan says the drug testing was approved for 
payment, but the code 83789 is not separately payable. 
 
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 the unspecified mass spectrometry testing 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 the unspecified mass spectrometry testing provided with drug 
testing on January 26, 2022, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) and complete 
mandibular dentures (D5120) provided on October 5, 2021. 
 
You asked the Plan to pay for dentures. You say that you need the dentures because of having another 
procedure The Plan denied your request. The Plan says complete maxillary and mandibular dentures are not 
covered by the Plan's benefits. 
 
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 complete maxillary dentures 
(D5110) and complete mandibular dentures (D5120) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT of dental arch (D0366) provided on February 
17, 2022. 
 
You asked the Plan to pay for dental imaging. You say that you had x-rays prior that could not locate the 
infection, so you had to get a 3D x-ray. The Plan denied your request. The Plan says cone beam CT of dental 
arch (D0366) is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT of dental arch (D0366) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the medical eye exam services provided on 
January 7, 2022. 
 
You asked the Plan to pay additionally for the medical eye exam services. You say that you would like the Plan 
to reconsider your request. The Plan denied your request. The Plan says they have now overturned the denial of 
payment for the medical eye exam, leaving you only responsible for your out-of-network copayment per your 
contract with the Plan. 
 
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 $55 
copayment for out-of-network vision care services for the diagnosis and treatment of diseases and injuries of 
the eye.   
You have been asked to pay a $16.32 copayment for the medical eye exam services provided by an out-of-
network provider, which is less than the contracted $55 copayment amount. The medical eye exam services fall 
within the Vision care 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 pay additionally for the medical eye 
exam services provided on January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (CPT code 63655). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service 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 the service. Our physician reviewer 
found the wrong code was used to request the services. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural (CPT 
code 63655).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100) provided on August 25, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment is made for this code 
per Medicare billing regulations. 
 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 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 the 
anesthesia services (99100) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) provided by a network 
provider on October 7, 2021. 
 
You asked the Plan to pay for the comprehensive exam (D0150). You say that the dentist received your 
medical records and knew that you already had a comprehensive exam done on May 21, 2021. The Plan denied 
your request. The Plan says the service exceeded the frequency limitation in the 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 Plan has a maximum benefit of one 
comprehensive exam per three plan year. The comprehensive exam (D0150) is not covered because the Plan 
paid for a comprehensive exam (D0150) on May 4, 2021, which exhausted your benefit. Therefore, we decided 
that the Plan does not have to pay for the comprehensive exam (D0150) provided by a network provider on 
October 7, 2021.  
 Your complaint that the dentist was crooked is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided on November 15, 2021. 
 
You asked the Plan to pay for the walking boot. You say that this should be covered due to medical necessity. 
The Plan denied your request. The Plan says the POS code billed for the walking boot does not match the 
location it will primarily be used, which is in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code for DMEPOS claims should reflect 
the location in which the equipment will be used.  
 
This code was billed with an office POS code. This should be reported as home where the boot will be 
primarily used. Therefore, we decided that the Plan does not have to pay for the walking boot provided on 
November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided with drug 
testing on December 17, 2021. 
 
You asked the Plan to pay for the unspecified mass spectrometry. You say that these services should be paid. 
The Plan denied your request. The Plan says the services described by code 83789 are specimen validity testing 
that cannot be separately paid. 
 
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 the unspecified mass spectrometry 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 the unspecified mass spectrometry provided with drug testing 
on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2335) provided on February 21, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2335) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) and teeth added to 
existing partial denture (D5650) provided on February 14, 2022. 
 
You asked the Plan to pay for fixed partial denture sectioning and teeth added to existing partial denture. You 
say that you feel this was necessary, therefore, you are asking for a reconsideration. The Plan denied your 
request. The Plan says the services are not covered under the member's contract under any normal 
circumstances. 
 
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. This benefit does not include 
fixed partial denture sectioning (D9120) and teeth added to existing partial denture (D5650). 
 
We looked at the file, the Plan's rules, and Medicare's rules. Fixed partial denture sectioning (D9120) and teeth 
added to existing partial denture (D5650) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) and teeth added to 
existing partial denture (D5650) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81345 provided on September 
2, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed as the 
testing was ordered by an in-network provider. The Plan denied your request. The Plan says a modifier was not 
billed with this code to indicate that it should be separately paid. 
 
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 81345 
is a column II code to column I code 0089U. 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 the laboratory services coded 81345 provided on September 2, 2021.