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

 
We decided that the Plan does not have to pay for the fluoride treatment (code D1206) you received from your 
dentist on October 27, 2020. 
 
You asked the Plan to pay for code D1206. You say that this should be covered by the Plan.  You said that the 
only reason you received this service is because it's part of your benefits. The Plan denied your request. The 
Plan says this service is not covered under your dental benefit. 
 
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.  Although your Plan does cover fluoride treatments, it only covers 
those treatments billed with code D1208.   Your provider did not bill this service with code D1208-- they billed it with D1206.  Services represented by code D1206 are not covered under your dental benefit. Therefore, we decided that the Plan does not have to pay for the fluoride treatment (code D1206) you received from your dentist on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 19, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 19, 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 
19, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of March 19, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 19, 2022, as she was not a danger to 
herself 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 the enrollee's 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 19, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 19, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided on October 5, 2021. 
 
You asked the Plan to pay for the dental service. You say that extractions were offered last year on your dental 
plan. You say that you were not aware that it was not covered in your plan this year. You also say that this was 
the cheapest option. The Plan denied your request. The Plan says the 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, the extraction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) 
provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure rendered on October 12, 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 procedure code 38792 is not supported. 
 
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 38792 is injection procedure; radioactive tracer for 
identification of sentinel node. 
 
We find that CPT code 38792 is not supported in the medical record. Specifically, there is no documentation of 
an injection procedure for radioactive tracer for identification of sentinel node. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the injection procedure rendered on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an oral surgeon. 
 
You asked the Plan to pre-approve these services. You say that you need to have your teeth extracted because 
they could cause an infection. The Plan denied your request. The Plan says that your contract only provides 
coverage for dental services when they are performed by a participating General Dentist. 
 
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 say that dental 
services must be performed by a participating general dentist. 
 
We looked at the file and Plan rules. The file indicates you are requesting these services be provided by a oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve dental services provided by an oral 
surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 2), and scaling and 
root planing (D4341 x 2) provided on June 24, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that you had dental 
coverage. You say that it was difficult to find a provider that was in network. You say that if you had known 
you would be billed for your visits, you would not have joined this plan. You also say that you cannot afford to 
pay this bill. The Plan denied your request. The Plan says no additional payment will be made. 
 
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 and 1 periapical x-ray is covered per 
calendar year with a 50% coinsurance when received out of network, the frequency limit has been exceeded. 
The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in 
this case. Additionally, scaling and root planing is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 2), and scaling and root 
planing (D4341 x 2) provided on June 24, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) performed by 
an endodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation performed by an endodontist. You say that 
the service is medically necessary. The Plan denied your request. The Plan says the service at issue is not 
covered unless it is performed by a participating general dentist. Dental services performed by an endodontist 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation performed by an endodontist have not been met. Specifically, the 
service at issue is not covered unless it is performed by a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) performed by an 
endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on October 12, 2021. 
 
You asked the Plan to pay for the pulp vitality test. You say that this service was necessary and should be 
covered. The Plan denied your request. The Plan says this service is not covered by your 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 the pulp 
vitality test (D0460) provided on October 12, 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) provided August 2, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you don't feel the provider should be 
paid for the services. The Plan denied your request. The Plan says they will cover the other services received on 
this date of service, but you have exceeded the frequency limit for this service. The Plan also says that they are 
looking at your concerns about the provider in a separate case. 
 
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 plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered May 6, 2019. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third transforaminal epidural injections (TFESI). 
 
You asked the Plan to pre-approve a third TFESI. You say that this is medically necessary for your condition. 
The Plan denied your request. The Plan says Medicare rules limit this service when performed on the same day 
to two levels. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not considered medically reasonable and 
necessary to perform Transforaminal Epidural Steroid Injections (TFESIs) at more than two (2) nerve root 
levels during the same session. 
 
We looked at the file and Medicare rules. This request is specifically for a third level of TFESIs beyond the 2 
approved levels. An additional level will not be covered according to Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of a third TFESI have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a third transforaminal epidural injections (TFESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 21, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 21, 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 
21, 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 21, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond March 21, 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 21, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 21, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 7, 2021. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you advised your dentist not to perform a full 
mouth x-ray. You also say that you received a statement showing you had a $0 balance. The Plan denied your 
request. The Plan says 1 panoramic x-ray is covered in a 3 year period. The Plan also says that the frequency 
limit 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 and panoramic x-ray is listed as a 
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for panoramic x-ray that you received on December 1, 2021. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0120) provided by a participating 
provider on November 22, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you wanted the dentist to do a follow-up 
due to the problems you encountered. The Plan denied your request. The Plan says the benefit limit for D0120 
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. The Plan covers two limited 
oral evaluation every year. 
 
We looked at the file and Medicare rules. Evidence was provided that show D0120 was provided on March 17, 
2021, and November 2, 2021. Based on this information, we decided that the Plan's rules for coverage of a 
limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0120) provided by a participating provider on November 22, 2021.
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 
June 7, 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 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 Plan's coverage rules apply in this case. The Plan covers limited dental 
services when the services are 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 June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental service. You say that you required an additional treatment this year 
due to not being able to receive one at the end of the previous year. You also say that you feel this service 
should be covered due to the extenuating circumstances as a result of the pandemic. The Plan denied your 
request. The Plan says 2 prophylaxis procedures are covered per plan year. The Plan also says that the 
frequency limit 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 and 2 prophylaxis procedures are 
covered per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for 
prophylaxis that you received on April 2, 2021, and June 4, 2021. Therefore, we decided that the Plan does not 
have to pay for the prophylaxis (D1110) provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) 
provided by an out-of-network provider on November 15, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation (D0120), and prophylaxis. You say that you go three 
times a year. You say that you would like this paid. The Plan denied your request. The Plan says the benefit 
limit for D0120 and D1110 have 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 Plan's coverage rules apply in this case. The Plan covers a periodic 
oral evaluation (D0120), and prophylaxis twice a year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0120 and D1110 were 
provided on March 3, 2021, and July 8, 2021. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation (D0120), and prophylaxis have already been met. Therefore, we decided 
that the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) provided by 
an out-of-network provider on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair resin partial denture base, maxillary (D5612) 
provided November 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the upper partial denture base repair. You say that you feel this should be 
covered by your dental plan. The Plan denied your request. The Plan says the service is not covered because it 
was provided OON. 
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 upper 
partial denture base repair when you see a participating dental provider. 
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. 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 upper partial denture base repair have not been met. Therefore, we decided that the Plan does not have to 
pay for the repair resin partial denture base, maxillary (D5612) provided November 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 18, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that this service should be covered as you 
have only had one periodontal maintenance cleaning this year. You also say this was a regular cleaning. The 
Plan denied your request. The Plan says this service is covered once every 6 months. You had a previous 
periodontal maintenance cleaning on July 13, 2021, which is less than 6 months before the date in question. 
 
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 says periodontal 
cleanings are covered once every 6 months following active periodontal therapy, not to be combined with 
regular cleanings. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance is 
requested in a frequency that is not covered under this benefit. Documentation shows your last periodontal 
cleaning was provided less than 6 months before this date. Therefore, we decided that the Plan does not have to 
pay for periodontal maintenance (D4910) provided on November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Formagraft and Medtronic Infuse Allograft 
(20930). 
 
You asked the Plan to pre-approve Nuvasive Formagraft and Medtronic Infuse Allograft. You say that these 
services are medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Nuvasive Formagraft and Medtronic 
Infuse Allograft. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested services are experimental and more 
research is needed before they can be considered medically reasonable and 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 Nuvasive Formagraft and Medtronic Infuse Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Nuvasive Formagraft and Medtronic Infuse Allograft (20930).