Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitored anesthesia services. 
 
You asked the Plan to pre-approve monitored anesthesia services. You say that monitored anesthesia care is 
medically necessary to accompany the pain injection services. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the use of Moderate or Deep Sedation, General 
Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for pain 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 monitored anesthesia services. Our 
reviewer says that the requested anesthesia services are not medically reasonable and necessary. Our physician 
reviewer found there is no documentation that this patient has any physical, psychological, or concerns about the patient's airway to warrant the use of monitored anesthesia care provided by a separate provider. Therefore, 
the requested monitored anesthesia care during the performance of the procedure is not medically necessary. 
The review has determined that the enrollee does not have a unique circumstance for monitored anesthesia 
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 monitored anesthesia services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve monitored anesthesia services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for oral hygiene instructions (D1330) provided on 
December 5, 2019. 
 
You asked the Plan to reimburse you for oral hygiene instructions. You say that you visited this provider and 
had services that were allowed and covered by your Plan. You also say that you should not be responsible to 
pay for something that was not done. The Plan denied your request. The Plan says there is no coverage for oral 
hygiene instructions. 
 
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. The records show that you had dental services done on the date of 
service. The Plan paid the allowed amount for those covered services. Specifically, oral hygiene instructions 
are not listed as a covered benefit with your Plan. Therefore, we decided that the Plan does not have to 
reimburse you for oral hygiene instructions (D1330) provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and first intraoral 
periapical x-ray (D0220) provided on December 14, 2021. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue and first intraoral periapical x-ray. You say 
that you would like these services to be covered. The Plan denied your request. The Plan says the incisional 
biopsy of oral tissue is not a covered expense under your dental plan. The Plan also says that your benefits for 
the first intraoral periapical x-ray have 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 incisional biopsy of oral tissue 
(D7286) is not among those covered under this benefit. The contract says that intraoral x-rays and are limited to 
one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray 
(D0220) on October 27, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and first intraoral periapical x-ray 
(D0220) provided on December 14, 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 
December 7, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like reimbursement from the Plan. 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 limited dental 
services when the services are provided by participating providers. 
 
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 December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate denture - maxillary (D5130). 
 
You asked the Plan to pre-approve an immediate upper denture. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service exceeds the Plan's frequency 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. The Plan covers an immediate 
upper denture once every five years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture was 
previously covered on August 24, 2020. Based on this information, we decided that the Plan's frequency limit 
for coverage of an upper denture will be exceeded with the requested service. Therefore, we decided that the 
Plan does not have to pre-approve an immediate denture - maxillary (D5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem 
focused (D0140) provided July 8, 2021, and the inhalation of nitrous oxide/analgesia, anxiolysis (D9230), 
extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and removal of torus 
mandibularis (D7473) provided July 15, 2021. 
 
You asked the Plan to provide additional payment for the limited oral exam, analgesia, tooth extractions and 
removal of torus mandibularis. You say that these services were necessary so you could eat. The Plan denied 
your request. The Plan says the claims processed correctly according to your OON 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. The Plan benefit states that the 
Plan only pays up to a certain amount for OON services. If you see an OON provider, you may be responsible 
for charges above what the Plan pays.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the limited oral 
exam, nitrous oxide and tooth extractions were covered according to the plan contract up to the Plan's allowed 
amount for the services. The services were provided OON and you are additionally responsible for the 
difference between the Plan's allowed amount and the total amount charged by the OON provider. Though the 
Plan offers dental benefits in excess of Medicare coverage, the removal of torus mandibularis is not among 
those covered services.  Therefore, we decided that the Plan does not have to provide additional payment for 
the limited oral evaluation - problem focused (D0140) provided July 8, 2021, and the inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230), extractions, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140), and removal of torus mandibularis (D7473) provided July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4342) 
provided on April 5, 2021. 
 
You asked the Plan to pay more for the scalings and planings. You say that you thought you were receiving a 
regular cleaning, but they did a periodontal cleaning which they charged $56.00. You also say that you 
did not want a periodontal cleaning and would like to request that the monies be refunded. The Plan denied 
your request. The Plan says the Plan's approved payment for each quadrant is $28, your 50% coinsurance 
would be $14 per quadrant, and the total cost sharing for all four quadrants is $56. The Plan also says that this 
claim processed correctly, and the provider may bill you $56. 
 
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, you are responsible for a 50% 
coinsurance for supplemental comprehensive dental services. Therefore, we decided that the Plan does not have 
to pay more for the periodontal scalings and root planings (D4342) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete maxillary denture (D5110) provided on 
October 7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the complete maxillary denture. You say that you thought the policy would 
cover 25% for one full denture and one partial denture rendered by an OON dentist. The Plan denied your 
request. The Plan says this service was rendered by an OON provider, and OON dentists have not agreed to 
provide services at contracted fees. If you see an OON dentist, the coinsurance level will apply to the average 
negotiated in-network fee schedule (INFS) in your area. The Plan also says that you are responsible for the 
difference between the INFS and dentists' charged fees when visiting an OON dentist. 
 
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, you are responsible for a 75% 
coinsurance, plus the difference between the billed amount and allowed amount because this service was 
received OON. Therefore, we decided that the Plan does not have to pay more for the complete maxillary 
denture (D5110) provided on October 7, 2021 by an out-of-network (OON) provider.  
 
Your complaint about being misled and not being fully informed by the Plan's representatives you spoke with 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 7 extractions (D7140) and alveoloplasty (D7311) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have been under cancer treatments since 
2015. You also say that these services should be covered. The Plan denied your request. The Plan says 
extractions and alveoloplasty are not listed as covered services by the plan or 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 extractions and alveoloplasty are 
not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pay for the 7 extractions (D7140) and alveoloplasty (D7311) provided on November 
10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on 
September 13, 2021. 
 
You asked the Plan to pay for the additional x-ray. You say that this service should be covered, and you were 
told this provider is in-network. The Plan denied your request. The Plan says this provider is in-network, and 
this claim has been paid at the network rate. However, on this date you received two intraoral x-ray images. 
Your dental benefit covers a maximum of one intraoral x-ray per plan year, regardless of the participation 
status of the provider. 
 
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 intraoral 
x-ray per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-ray is requested in a 
frequency that is not covered under this benefit. Documentation shows that you had two intraoral x-rays on the 
date in question, and one was paid for and covered by the Plan. Therefore, we decided that the Plan does not 
have to pay for the additional intraoral x-ray (D0230) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
December 22, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you received bitewing x-
rays. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
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 
complete series of intraoral x-rays (D0210) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the scaling and gingival irrigation. You say that you need these services and 
would like the Plan to cover them. The Plan denied your request. The Plan says these services are not covered 
under your benefit package. 
 
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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) and gingival irrigation 
(D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you would like these implants to be 
approved for coverage because you are missing teeth, cannot eat right, and are losing weight. The Plan denied 
your request. The Plan says this service is 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 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 
surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the osseous surgery (D4260) 
provided on May 27, 2021. 
 
You asked the Plan to reimburse an additional amount for the dental service. You say that you paid the 
provider a previous balance of $624.70. You say that you are eligible for reimbursement up to the limit of your 
policy. You also say that you were advised you would be paid $307.21. The Plan denied your request. The Plan 
says there is a $1,000 annual maximum benefit for dental services. The Plan also says that the maximum 
benefit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the 
annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $246 for services 
received on April 13, 2021, $172 for services received on September 28, 2021, and $446.79 for services received on May 27, 2021. The record shows that the Plan reprocessed this claim to pay an additional $135.21. 
$246 + $172 + $446.79 + $135.21 = $1,000. Additionally, the Evidence of Coverage clearly states that you are 
responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have 
to reimburse an additional amount for the osseous surgery (D4260) provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel that this service should be considered 
part of the crown. You say that they should not be billed as separate services. You also say that this service 
should have been covered in full. The Plan denied your request. The Plan says core build up 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 core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950) 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 (D0140) provided on November 
17, 2021. 
 
You asked the Plan to pay for the dental service. You say that the claim was denied for just being seen at the 
dental office. The Plan denied your request. The Plan says 1 limited oral evaluation is 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on September 2, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the prodigy blood glucose monitor, testing strips, control solutions and sterilance lancets and lancing device, provided on April 15, 2020.
You asked the Plan to pay for the diabetic testing supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says these are not the preferred brands.
The Plan must follow Medicare rules. Medicare rules say that A plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers. 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 for diabetic testing supplies. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no indication as to why the requested items are medically necessary over the Plan's preferred brand. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for the prodigy blood glucose monitor, testing strips, control solutions and sterilance lancets and lancing device, provided on April 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on June 3, 2021, billed with 
two units of 88321-91. 
 
You asked the Plan to pay for the pathology services as billed. You say that this should be paid as the use of 
modifier -91 allows payment for additional units. The Plan denied your request. The Plan says 88321 has an MUE of 1 with an MAI of 2. This means more than one unit is never payable to the same provider on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
pathology services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
pathology services provided on June 3, 2021, billed with two units of 88321-91.