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

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
December 7, 2020, and October 26, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. 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 dental 
services provided by a participating provider on December 7, 2020, and October 26, 2021.
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) and intraoral - complete series of radiographic images (D0210) provided March 23, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of intraoral x-rays. You say 
that you don't feel these services were provided to you. The Plan denied your request. The Plan says they have 
confirmed with the provider's office that these services were received, and you have exceeded the frequency 
limit for these services. 
 
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 covers the 
comprehensive oral exam once every three years and a complete series of intraoral x-rays once every five 
years.  
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and complete series of x-rays were previously covered on December 5, 2019. Based on this information, 
we decided that the Plan's frequency limit for coverage of the comprehensive oral exam and complete series of 
intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) provided March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for antimicrobial agents (D4381 x 13) and unspecified 
periodontal procedure (D4999) provided from September 20, 2021, to November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like for some of these services to be 
covered. The Plan denied your request. The Plan says antimicrobial agents and unspecified periodontal 
procedure are not listed as covered services. 
 
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 antimicrobial agents and 
unspecified periodontal procedure are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for antimicrobial agents (D4381 x 13) and unspecified periodontal procedure 
(D4999) provided from September 20, 2021, to November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride varnish (D1206) provided on November 3, 2021. 
 
You asked the Plan to pay for the fluoride varnish. You say that your dentures did not fit properly. You say that 
you had an old denture that your dentist offered to add a tooth to. You also say that the dentist promised to 
refund the payment to your insurance, then recharge for the work that was done. The Plan denied your request. 
The Plan says fluoride varnish is not listed as 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride varnish is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fluoride varnish (D1206) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950), porcelain crown (D2740), gum 
medication (D4381), and scaling and root planing (D4342). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not listed as covered 
services. 
 
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 core build up, porcelain 
crown, gum medication, and scaling and root planing are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve core build up (D2950), porcelain crown 
(D2740), gum medication (D4381), and scaling and root planing (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia - each subsequent 15-
minute increment (D9223), periodic oral evaluation - established patient (D0120), extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), bitewings - four radiographic images (D0274) and occlusal adjustment - limited (D9951) 
provided October 1, 2021, and October 26, 2021, by out-of-network (OON) providers. 
 
You asked the Plan to pay for the deep sedation, periodic oral exam, tooth extractions, bitewing x-rays and 
occlusal adjustment. You say that you wanted to go to good doctor for necessary services. The Plan denied 
your request. The Plan says the services were provided OON and are not covered. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the deep 
sedation, periodic oral exam, tooth extractions, bitewing x-rays and occlusal adjustment when the services are 
provided by a participating provider.  
 
We looked at the file, and Medicare rules. The requested providers in this case are not network providers with 
the Plan's dental vendor. The Plan had network providers available who could have provided the items/services 
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that 
would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's 
rules for coverage of the deep sedation, periodic oral exam, tooth extractions, bitewing x-rays and occlusal 
adjustment have not been met. Therefore, we decided that the Plan does not have to pay for the deep 
sedation/general anesthesia - each subsequent 15-minute increment (D9223), periodic oral evaluation - 
established patient (D0120), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210), bitewings - four radiographic images (D0274) 
and occlusal adjustment - limited (D9951) provided October 1, 2021, and October 26, 2021, by out-of-network 
(OON) providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 10, 2021 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the dental services. You say that you have always paid out of pocked and 
received a direct member reimbursement with no issue. You also say that the direct member reimbursement 
benefit reimburses any licensed dentist in the United States, in or out-of-network. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
The Plan also says that the treating provider opted out of Medicare effective November 8, 2013, to November 
8, 2023. 
 
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 received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the dental services provided on September 10, 2021 by a Medicare opt out 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 9, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that you 
should not be charged for this service. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 1, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you needed an exam to determine what 
treatment was needed for a broken tooth. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for this service. 
 
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 covers two 
preventative oral exam per calendar year. 
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that oral exams were 
previously covered on March 3, 2021, and September 8, 2021. Based on this information, we decided that the 
Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 16, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 16, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
16, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 16, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond March 16, 2022, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 16, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 16, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and crown (D2750) provided on October 21, 2021. 
 
You asked the Plan to pay for the core buildup and crown. You say that it is your understanding that it is the 
responsibility of the dental office to confirm that all procedures are fully covered under your insurance plan 
prior to the service being rendered. You also say that you are on a fixed income, have no financial resources 
available to pay any bills, and would never have agreed to these services if you had known the provider would 
demand payment for these services. The Plan denied your request. The Plan says the core buildup is not a 
covered expense under your dental plan. The Plan also says that your crowns benefit has been satisfied and the 
frequency limitation has been exceeded. 
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 core buildup, including any pins 
when required (D2950) is not among those covered under this benefit. The contract says that crowns are 
limited to two procedure codes per calendar year. The record shows that you received two crowns (D2750 x2) 
on March 11, 2021 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the core buildup, including any pins when required (D2950) and crown (D2750) provided on 
October 21, 2021.
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 August 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were never 
notified that the request for termination from this Plan network had been processed. You also say that had you 
been properly notified you could have informed the patients that the treating provider was no longer a 
participating provider. The Plan denied your request. The Plan says these OON services are not covered 
because the enrollee's plan has no OON benefits. The Plan also says that you did not contact the Plan prior to 
this date of service to verify benefits or your provider status for this enrollee. 
 
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 received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120) and prophylaxis (D1110) provided on August 12, 2021 by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that more than 6 pathogens were tested. 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 laboratory services provided on August 16, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites (D2391, D2392, and D2393). 
 
You asked the Plan to pre-approve the resin-based composites. You say that you are under financial urgency, 
and you cannot afford to pay for these services. You also say that the fillings are medically necessary. 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 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 pre-approve 
resin-based composites (D2391, D2392, and D2393).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic imaging (D0220 and D0230) provided 
by a participating provider on October 7, 2021. 
 
You asked the Plan to pay for intraoral radiographic imaging. You say that you thought that bitewings were 
covered. You say that you were unaware that these services were not covered. The Plan denied your request. 
The Plan says intraoral imaging is not a covered dental 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 intraoral 
radiographic imaging (D0220 and D0230) provided by a participating provider on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210), removal of residual tooth 
roots (D7250), initial 5 minutes of deep sedation (D9222), and additional 15 minutes of deep sedation (D9223 
x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you need your tooth to be extracted. You 
say that your tooth is causing your pain. You also say that you do not want to get an infection. The Plan denied 
your request. The Plan says surgical extraction is not listed as a covered service. The Plan says that deep 
sedation services are not listed as covered. The Plan also says that these services are not covered by 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, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical 
extraction (D7210), removal of residual tooth roots (D7250), initial 5 minutes of deep sedation (D9222), and 
additional 15 minutes of deep sedation (D9223 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate conscious sedation services (99152). 
 
You asked the Plan to pre-approve moderate conscious sedation services. You say that this care is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is no medical necessity for an 
exception specifically for moderate conscious sedation services. 
 
The Plan follows Medicare rules. Medicare rules say that use of Moderate or Deep Sedation, General 
Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for epidural 
injection procedures and therefore not considered medically reasonable and necessary. Even in patients with a 
needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation 
must clearly establish the need for such sedation in the specific patient. 
 
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 moderate conscious sedation services. 
Our reviewer says that the requested services are not medically reasonable and necessary.  
Our physician reviewer found that the clinical records provided do not support that the enrollee's condition 
warrants the need of monitored anesthesia care/moderate sedation during epidural steroid injection services. 
There is no unique medical circumstance presented that supports an exception to establish the need for sedation 
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 moderate conscious sedation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve moderate conscious sedation services (99152).