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

 
We decided that the Plan does not have to pay for the crown (D2740) and the prefabricated post and core 
(D2954) provided by a non-plan dentist on February 2, 2022. 
 
You asked the Plan to pay for the crown (D2790) and the prefabricated post and core (D2954). You say that 
you are appealing this claim. The Plan denied your request. The Plan says the 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 crown (D2740) and the 
prefabricated post and core (D2954) are not among those covered under this benefit when provided by an out-
of-network dentist. The record shows the dentist was out-of-network. Therefore, we decided that the Plan does 
not have to pay for the crown (D2740) and the prefabricated post and core (D2954) provided by a non-plan 
dentist on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the dental services provided on June 8, 2021. 
 
You asked the Plan to make additional payment for the dental services. You say that you feel that this was 
processed incorrectly. The Plan denied your request. The Plan says this claim was reprocessed three times. In 
each processing, more reimbursement was issued. The total reimbursement from the three checks totaled $775. 
As such, your dental benefit was exhausted. 
 
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, this is limited to $775 per year. The 
file shows that the Plan issued three checks to you, one in the amount of $331.60, one in the amount of 
$404.80, and a final one paying out $38.60. This totals $775. Therefore, we decided that the Plan does not have 
to make additional payment for the dental services provided on June 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services (99285).
You asked the Plan to pay for the emergency room services. You say that the service should be covered. The Plan denied your request. The Plan says they were previously billed by and paid another provider for this service.
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. 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 the emergency room services (99285). have been met. Specifically, there is no indication this service was provided twice on this date of service. Therefore, we decided that the Plan does not have to pay for the emergency room services (99285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Deep Sedation/General anesthesia first 15 minutes 
(D9222). 
 
You asked the Plan to pre-approve Deep Sedation/General anesthesia first 15 minutes. You say that the service 
is medically necessary. The Plan denied your request. The Plan says this 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 pre-approve Deep 
Sedation/General anesthesia first 15 minutes (D9222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
December 6, 2021. 
 
You asked the Plan to pay for bitewings. You say that you had panoramic imaging done in May. You say these 
are bitewings. The Plan denied your request. The Plan says the benefit limit for the rendered services has 
already been met and 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. The Plan covers one set of 
bitewings per calendar year. 
 
We looked at the file and Medicare rules. The rendered services were previously provided on May 26, 2021. 
Based on this information, we decided that the Plan's rules for coverage of bitewings have not been met. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided by a participating 
provider on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing resin for cervical and/or root 
surface, per tooth (D9911) provided February 15, 2022. 
 
You asked the Plan to pay for desensitizing resin. You say that you have very sensitive teeth and this treatment 
has life-changing effects. The Plan denied your request. The Plan says this service is 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 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 the 
application of desensitizing resin for cervical and/or root surface, per tooth (D9911) provided February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81275, 81276, and 
81301 provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 81206, 81275, 81276, and 81301 are not supported in the medical record. Specifically, 
when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Review of the file does not support that only one code was submitted for the panel 
rendered. 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 coded 
81206, 81275, 81276, and 81301 provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the limited oral evaluation (D0140) and the intraoral-periapical first 
radiographic image (D0220) provided on February 2, 2022. We also decided that the Plan does not have to pay 
for the limited oral evaluation (D0140), the intraoral-periapical first radiographic image (D0220), and the pulp 
vitality test (D0460) provided on February 24, 2022.   
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan says that the limited oral evaluations and the periapical radiographic images 
provided exceed the allowable frequency benefit for these services. Additionally, the pulp vitality test is not a 
covered benefit.  
 
We decided that the Plan has to pay for the limited oral evaluation (D0140) and the intraoral-periapical 
first radiographic image (D0220) provided on February 2, 2022. The Plan has stated their denial was issued 
as you had exceeded the allowable frequency for these services provided. The rules say that Medicare plans 
must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity 
(IRE). The Plan has not provided evidence to support their denial issued for these services; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140) and 
the intraoral-periapical first radiographic image (D0220) provided on February 2, 2022.  
 
We also decided that the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral-
periapical first radiographic image (D0220), and the pulp vitality test (D0460) provided on February 24, 
2022. The pulp vitality test is not a covered benefit under your contractual policy. Additionally, the Plan 
contract states that one exam is covered every six months and one periapical radiographic image is covered 
every three years. You have previously received these services on February 2, 2022. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral periapical first radiographic 
image (D0220), and the pulp vitality test (D0460) provided on February 24, 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 pre-approve complete upper and lower dentures (D5110, D5120). 
 
You asked the Plan to pre-approve complete upper and lower dentures. You say that you are currently without 
dentures. The Plan denied your request. The Plan says this request exceeds the frequency limitation for 
dentures. 
 
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, it covers complete dentures only once 
every five years. The file shows that you previously received dentures in December of 2020, less than five 
years ago. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures 
(D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power lift chair purchased on December 28, 2021. 
 
You asked the Plan to pay for the services. You say that a power lift chair purchased on December 28, 2021. 
The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
provided is not clear with regards to the requested power seat lift chair in terms of the course of treatment. 
Home physical and occupational therapies were requested but there is no discussion as to the necessity of the 
power lift chair. The power lift chair is not likely to improve your condition.  You already have a Hoyer lift for transfers if needed. The documentation indicates that you are not ambulating. 
Given that the above criteria have not been met, the requested power lift chair is not covered by Medicare and 
cannot be considered medically necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a power lift chair purchased on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia services. 
 
You asked the Plan to pre-approve anesthesia. You say that you need anesthesia because you cannot take the 
pain and you do not want to be uncomfortable during the procedure. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
anesthesia services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dentures received on January 31, 2022. 
 
You asked the Plan to pay for the dentures. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the services received exceed your benefit limit. 
 
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. 
 
Review of the file shows that you previously received dentures on March 16, 2020. Five plan years had not 
passed since you previously received dentures. This means you have exceeded the benefit limit. Therefore, we 
decided that the Plan does not have to pay for the dentures received on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental periodic examination (code D0120) provided on 
January 24, 2022. 
 
You asked the Plan to pay for dental exam. You say that this was provided by an endodontist and not your 
regular dentist. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because one examination is covered every 6 months and you previously received an exam on September 17, 2021. 
 
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 one exam 
every 6 months. 
 
We looked at the file, the Plan's rules, and Medicare rules. You previously received a covered exam on 
September 17, 2021; therefore, the benefit was exhausted for date of service January 24, 2022. Therefore, we 
decided that the Plan does not have to pay for a dental periodic examination (code D0120) provided on January 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the pontic - porcelain/ceramic 
(D6245), retainer crowns - porcelain/ceramic (D6740), prefabricated post and core in addition to crown 
(D2954) provided January 4, 2022, and the core buildup, including any pins when required (D2950), and crown 
- porcelain/ceramic (D2740) provided January 21, 2022. 
 You asked the Plan to provide additional payment for the pontic, retainer crowns, post and core, core buildup, 
and crown. You say that you feel this should be covered since it is the first time you have had this service. The 
Plan denied your request. The Plan says these services have processed correctly up to your dental maximum. 
 
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 pontic, 
retainer crowns, post and core, core buildup, and crown with 50% coinsurance up to the Calendar Year 
Maximum of $1,000. If the Plan determines that a less expensive service can be performed with a 
professionally satisfactory result, the maximum the Plan will allow is the charge for the less expensive 
treatment.  
 
We looked at the file, and Medicare rules. The porcelain/ceramic crown (D2740) provided January 21, 2022, is 
being covered as a porcelain fused to metal crown (D2751) as the Plan has determined that this is the least 
costly method of treatment. This crown as well as the prefabricated post and core, pontic, and core buildup 
have been correctly covered with 50% coinsurance. The Plan paid your full $1,000 Calendar Year Maximum of 
$1,000 towards these services. Therefore, the retainer crowns are not covered because you have exhausted your 
benefit. Based on this information, we decided that the Plan's rules for coverage of the pontic, retainer crowns, 
post and core, core buildup, and crowns have not been met. Therefore, we decided that the Plan does not have 
to provide additional payment for the pontic - porcelain/ceramic (D6245), retainer crowns - porcelain/ceramic 
(D6740), prefabricated post and core in addition to crown (D2954) provided January 4, 2022, and the core 
buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) provided January 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 22, 2022. 
 
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 services provided by an out-of-network provider 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 Plans coverage rules apply in this case. The Plan covers covered 
dental services provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placement (D6010). 
 
You asked the Plan to pre-approve the implant placement. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this 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 pre-approve the 
implant placement (D6010).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve repair of the joystick control for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC joystick repair. You say that you do not want to have all of the 
requested repairs for this PWC. You just want to have the joystick repaired so you can use the PWC since it is 
due to be replaced soon anyway. The Plan denied your request. The Plan says that the requested repair cost is 
$4567.84 with $6477 of repairs having been covered in the past. Since the total cost of repairs is $11,044.84 
and the cost of replacement is $10,672.20, no payment for repairs can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs to equipment are covered up to the cost of 
replacement but cannot exceed the cost of replacement.   
 
We looked at the file and Medicare rules. Based on the letter we received from you, you do not wish to have all 
of the repairs that were requested by the provider. You only wish to have the joystick repaired. Though the 
documentation does not indicate the exact cost of this repair, it is presumed to be lower than $4195.20, which is 
the total amount that can be covered for repairs before reaching the cost of replacement. Therefore, we decided 
that the Plan has to pre-approve repair of the joystick control for a power wheelchair (PWC).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the therapy services provided on January 17, 2022. 
 
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the therapy services by a contract provider. The file does not show that the Plan provided 
notice that the therapy services would not be covered. The file does not contain any evidence showing the 
enrollee understood the services would not be covered. Under Medicare rules, this means the therapy services 
are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the therapy services 
provided on January 17, 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.