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

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214), provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary denture and a partial mandibular denture. You say that 
these services are medically necessary. The Plan denied your request. The Plan says the requested dental work 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) and a partial mandibular denture (D5214), provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided March 28, 2022. 
 
You asked the Plan to pay for the crown. You say that it makes more sense to put a crown on a fixed tooth than 
to pull it out. 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 crown 
- porcelain/ceramic (D2740) provided March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with field of view of both jaws; with or without cranium (D0383) and consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) provided March 10, 2022. 
 
You asked the Plan to pay for the cone beam CT scan and diagnostic consultation. You say that these services 
were necessary to make an informed decision about your dental options. The Plan denied your request. The 
Plan says these services are 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 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 cone beam computed tomography (CT) image capture with field of view of both jaws; with or without cranium 
(D0383) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) provided March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided by a participating 
provider on February 8, 2022. 
 
You asked the Plan to pay for a surgical extraction. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the rendered dental services are not covered. 
 
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 a surgical 
extraction (D7210) provided by a participating provider on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a palliative treatment of dental pain (D9110) provided on 
March 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 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 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 a 
palliative treatment of dental pain (D9110) provided on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete series (D0210) provided on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not realize you could only have dental 
x-rays every two years. 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 Plan's 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 September 10, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral complete series (D0210) provided on 
April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
limited oral evaluation - problem focused (D0140), and endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided February 18, 2021. 
 
You asked the Plan to pay for the core buildup, limited oral exam and root canal. You say that the appeal is late 
because of COVID-19. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the core buildup, limited oral exam and root canal was not filed until March 
28, 2022. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when 
required (D2950), limited oral evaluation - problem focused (D0140), and endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) provided February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (code D4921) and the oral hygiene 
instructions (code D1330) you received on April 6, 2022. 
 
You asked the Plan to pay for the gingival irrigation (code D4921) and the oral hygiene instructions (code 
D1330). You say that these services have been part of your routine cleanings due to gum bleeding and 
periodontal disease. You said that these services have kept your teeth and gums in good shape. The Plan denied 
your request. The Plan says these are not services that are 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 Plans coverage rules apply in this case.  The Plan only covers those 
dental services specifically listed in your dental benefits chart. The gingival irrigation (code D4921) and the oral hygiene instructions (code D1330) you received are not services listed in this chart, so they are not covered 
for any reason. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation (code D4921) and the oral hygiene instructions (code D1330) you received on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), and intraoral x-rays (D0210) provided on March 31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider was in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), 
prophylaxis (D1110), and intraoral x-rays (D0210) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on April 22, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental work is not a covered 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 a limited 
oral evaluation (D0140) provided by a participating provider on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on 
November 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that these visits were needed as a result of a tooth 
extraction.  You believe that because these were not regular visits, both of these visits should be covered. 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 October 20, 2021. 
Therefore, we decided that the Plan does not have to pay for the limited oral exam (code D0140) you received 
on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on March 14, 2022, to March
25, 2022.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital services that
were provided were medically necessary. The Plan denied your request. The Plan says that the medical criteria
for an inpatient hospital admission has not been met.
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 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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found could no longer handle the member's custodial needs due to dementia, incontinence and
occasional aggressive behavior.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided on March 14, 2022, to March 25, 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 pay for prophylaxis (D1110), a periodic oral evaluation (D0120), 
and bitewings (D0274) provided by an out-of-network provider on March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this 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 prophylaxis (D1110), a periodic oral evaluation (D0120), and bitewings (D0274) provided by an out-
of-network provider on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0274, D0120, D1110) provided on March 
3, 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 and were not made aware that some of your doctors were now 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 Plan's 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 dental services (D0274, D0120, D1110) provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax from the purchase of a power operated vehicle. 
 
You asked the Plan to pay for sales tax. You say that the power operated vehicle was a medical necessity for 
you. The Plan denied your request. The Plan says sales tax cannot be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not reimburse separately for sales tax. 
Based on this information, we decided that Medicare rules for coverage of sales tax have not been met. 
Therefore, we decided that the Plan does not have to pay for sales tax from the purchase of a power operated 
vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic dental x-ray (D0330) provided on January 13, 2022. 
 
You asked the Plan to pay for the panoramic dental x-ray. 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 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 a 
panoramic dental x-ray (D0330) provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on December 16, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you received your enrollment card on 
February 13, 20221 so you believed services were already covered. The Plan denied your request. The Plan 
says service codes 98940, 97140, and 97012 remain unpaid due to no active policy at the time. 
 
The records show that you had no active insurance policy at the time services were rendered on December 16, 
2021. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on December 
16, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to provide coverage for a computed tomography (CT) scan of the chest,
abdomen, and pelvis for the enrollee.
You asked the Plan to provide coverage for imaging. You say that this imaging is medically necessary. The
Plan denied your request. The Plan says that Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary. After we made our original decision, our Medical Director reviewed the case file. Our
Medical Director confirmed that Medicare coverage criteria are met. Our Medical Director found the NCCN
Guidelines Version 2.2022, for Biliary Tract Cancers: Gallbladder Cancer, states, under the heading
Surveillance, "Consider imaging every 3 to 6 months for 2 years, then every 6 to 12 months for up to 5 years,
or as clinically indicated." Therefore, per NCCN guidelines, surveillance CT scan at 3 months is medically
reasonable and necessary for this enrollee with gallbladder cancer. Medicare coverage criteria are met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan have been met. Therefore, we decided that the Plan has to provide
coverage for a computed tomography (CT) scan of the chest, abdomen, and pelvis for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  
 
The file shows that a power seat elevation system was requested. This item is non-covered because it is not 
primarily medical in nature. The file shows that an electronic connection was requested. The records do not 
show that two or more power options need to be controlled through a single interface. Based on this 
information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, 
we decided that the Plan does not have to pre-approve wheelchair options and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 31, 2021, billed with 
codes 81206, 81235 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 31, 2021, billed with codes 81206, 81235 and 81321.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve preparation of a dental splint for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this item will be used as a barrier to prevent 
infections. The Plan denied your request. The Plan says that this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
preparation of a dental splint for the enrollee.