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

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that you got approved for a crown and need the 
core buildup approved. The Plan denied your request. The Plan says multiple attempts were made to obtain 
documentation to support the medical necessity but was never received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the enrollees medical documentation and confirm that Medicare coverage criteria have been 
met. 
 
  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 dental service have been met. The 
documentation shows multiple attempts were made by the Plan to receive diagnostic x-rays to show the 
medical necessity for the dental service, but none were ever sent to the Plan. Therefore, we decided that the 
Plan does not have to pre-approve core buildup (D2950) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures were destroyed, and you 
need new dentures. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of March 5, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), sealant 
(D1351), and a panoramic radiographic image (D0330) provided on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary and should be 
covered. The Plan denied your request. The Plan says your benefit for the panoramic radiographic image has 
already been exhausted. Periodontal scaling and root planing, and sealant 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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service March 8, 2021. 
Additionally, periodontal scaling and root planing, and sealant are not covered benefits. Therefore, we decided 
that the Plan does not have to pay for periodontal scaling and root planing (D4341), sealant (D1351), and a 
panoramic radiographic image (D0330) provided on August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 
is a column II code to column I code 87632. 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 procedure code 87634 billed for date of service March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation and two root canals to be provided by an 
endodontist. 
 
You asked the Plan to pay for an oral evaluation and two root canals. You say that you are in pain, and your 
dentist provided you with antibiotics that are not working well. The Plan denied your request. The Plan says 
there is no listed benefit for a root canal. The Plan also says dental services provided by specialists, such as oral 
surgeons, periodontists, prosthodontists, orthodontists, and endodontists 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, root canals are not among those 
covered under this benefit. The contract also clearly states that dental services performed by anyone other than 
a participating general dentist are not covered. Therefore, we decided that the Plan does not have to pay for an 
oral evaluation and two root canals to be provided by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dentures. You say that you are in pain and need dentures that fit 
correctly. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) and complete mandibular denture (D5120) to be rendered by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture base (D5214). 
 
You asked the Plan to pre-approve dental service. You say that you need the dentures; you cannot eat properly. 
The Plan denied your request. The Plan says the service is covered but limitations apply. 
 
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. This benefit includes 
mandibular partial denture - cast metal framework with resin denture base (D5214)  one procedure allowed 
every five plan years. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered mandibular 
partial denture - cast metal framework with resin denture base (D5214) on June 02, 2020. Therefore, this 
benefit has been exhausted as of June 02, 2020. Therefore, we decided that the Plan does not have to pre-
approve mandibular partial denture - cast metal framework with resin denture base (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on July 28, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on July 28, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 22, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown () provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 22, 2019. 
Therefore, we decided that the Plan does not have to pay for a dental crown () provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical implant body (D6011), bone replacement 
graft (D7953), and desensitizing medicament (D9910) for tooth #9. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental procedures 
approved. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the surgical implant body, bone replacement graft, and desensitizing medicament are not covered by 
the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a 
surgical implant body (D6011), bone replacement graft (D7953), and desensitizing medicament (D9910) for 
tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2961) 
 
 
You asked the Plan to pre-approve the dental services. 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 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 a 
labial veneer (D2961)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), 
and bitewing radiographic images (D0274) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), and bitewing radiographic images 
(D0274) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teeth cleaning (D1110), and topical application of fluoride 
(D1206) provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for teeth cleaning (D1110), and topical application of fluoride (D1206) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture-maxillary (D5110) and complete 
denture-mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat solid foods which has 
affected your health and causing weight loss. You say you are experiencing pain and soreness on the upper part 
of your mouth. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested complete denture-maxillary (D5110) and complete denture-mandibular (D5120) but is limited to one 
upper complete and one lower complete denture every 5 years, including routine post-delivery care or partial 
dentures (upper and lower) one upper and/or one lower partial denture every 5 years, including routine post-
delivery care. Includes necessary extractions to fit dentures (unlimited). Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit was exhausted on date of service April 30, 2019, when you received maxillary partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5213) and mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214). Therefore, we decided that the Plan does not have to pre-
approve complete denture-maxillary (D5110) and complete denture-mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration, resorbable barrier, per site 
(D4266) Tooth #15 and bone replacement graft for ridge preservation, per site (D7953) Tooth #15. 
 
You asked the Plan to pre-approve dental services. You say that the services requested are needed for the 
enrollee. 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. Guided tissue regeneration, 
resorbable barrier, per site (D4266) and bone replacement graft for ridge preservation, per site (D7953) are not 
covered under the Plans dental benefits.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested guided tissue 
regeneration, resorbable barrier, per site (D4266) Tooth #15 and bone replacement graft for ridge preservation, 
per site (D7953) Tooth #15 are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve guided tissue regeneration, resorbable barrier, per site (D4266) Tooth #15 and 
bone replacement graft for ridge preservation, per site (D7953) Tooth #15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that if you do not get this equipment you may need to 
recover in a skilled nursing facility. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that a total knee arthroplasty is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation that the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We looked at the file and Medicare rules. In this case the provider has indicated that an overnight observation 
stay is appropriate. Thus, the provider does not feel that 2 midnights of care is medically necessary at this time. 
Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have 
not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care 
associated with an elective surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing coded as procedure codes 81227, 81225, 
81401 and 81230 provided May 18, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you have attached the documents that supports 
the CPT's ICD's billed on this claim. The Plan denied your request. The Plan says the molecular testing is not 
medically necessary and does not meet the requirements for approval. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a diagnosis of ischemic heart disease and long-term 
drug therapy. The record sent by his provider indicates the enrollee was managed with aspirin, clopidogrel, 
atorvastatin, atenolol, and nitroglycerin. There is no documentation in the medical record indicating concern or 
need for genetic testing or ineffective response to treatment. The requisition order for testing was signed by the 
provider on May 18, 2021 for MicroGen Health laboratory in Virginia and test results for Devansh Lab Werks 
in Alabama. Neither of these laboratories is listed on the Palmetto GBA DEX Diagnostics Exchange Registry. 
The review has determined that there is no specific clinical rationale for the requested genetic testing. The 
items/services at issue in this case are not medically reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing coded as procedure codes 81227, 81225, 81401 and 81230 provided May 18, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment, by report (D5862) x's 2 and 
overdenture, complete, mandibular (D5865). 
 
You asked the Plan to pre-approve dental services. You say that you are unable to use your bottom teeth. The 
Plan denied your request. The Plan says these services are 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 precision attachment, by 
report (D5862) and overdenture, complete, mandibular (D5865) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve precision attachment, by report 
(D5862) x's 2 and overdenture, complete, mandibular (D5865).