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

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 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 the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 laboratory services rendered on July 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a caudal epidural steroid injection (ESI) described with 
two units of code 62323. 
 
You asked the Plan to pre-approve the second unit of 62323. You say that this should be approved as the 
enrollee has not been helped by physical therapy. The Plan denied your request. The Plan says a single unit of 
62323 was approved as this is felt to be sufficient at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that a maximum of one level of caudal ESI is 
considered reasonable and necessary. It is also noted that predetermined numbers of ESIs are not medically 
reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case, it is not clear whether the two units requested were 
meant to describe two spinal levels of injection or two injection sessions. However, based on the LCD 
guidelines, these would both be considered not medically reasonable and necessary. Based on this information, 
we decided that Medicare rules for coverage of the second unit of 62323 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a caudal epidural steroid injection (ESI) described with two 
units of code 62323.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown (D2799). 
 
You asked the Plan to pre-approve the interim crown. The Plan denied your request. The Plan says 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 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 an 
interim crown (D2799).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
primary closure of a sinus perforation (D7261) provided October 7, 2021. 
 
You asked the Plan to pay for the limited oral exam and primary closure of a sinus perforation. You say that 
these services were necessary. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for the limited oral exam and the primary closure of a sinus perforation is not a covered service 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. The Plan covers the limited 
oral exam once per plan year.  
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on September 22, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the limited oral exam has been exceeded. Though the Plan offers dental 
benefits in excess of Medicare coverage, the primary closure of a sinus perforation is not among those covered 
benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused (D0140) and primary closure of a sinus perforation (D7261) provided October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2791), endodontic therapies (D3310), a 
maxillary partial denture (D5213), and a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the crowns, endodontic therapies, maxillary partial denture, and mandibular 
partial denture. You say that in reviewing the Office Reference Manual these services are covered benefits. The 
Plan denied your request. The Plan says these services are 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 
crowns (D2791), endodontic therapies (D3310), a maxillary partial denture (D5213), and a mandibular partial 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), intraoral x-ray (D0220), 
resin-based filling (D2331), surgical tooth extraction (D7210), bone replacement graft (D7953) and panoramic 
x-ray (D0330) provided on October 14, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that they accept your 
insurance, and you cannot afford this bill. The Plan denied your request. The Plan says the provider in this case 
is not part of the Plan's dental network. Services are only covered when received from a participating 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. The Plan says that 
supplemental dental services are only covered when performed by a provider who participates in the Plans 
dental network. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral exam (D0140), intraoral x-ray (D0220), resin-based filling (D2331), surgical tooth 
extraction (D7210), bone replacement graft (D7953) and panoramic x-ray (D0330) provided on October 14, 
2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) and a consultation, diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) provided on 
September 16, 2021, to September 30, 2021. 
 
You asked the Plan to pay for a tooth extraction and a consultation, diagnostic service. You say that you 
disagree with the denial of your claim. The Plan denied your request. The Plan says the requested services are 
not covered benefits with your Plan. 
 
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 tooth 
extraction (D7210) and a consultation, diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310) provided on September 16, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) and partial lower denture 
(D5214) provided on October 1, 2021. 
 
You asked the Plan to pay for partial dentures. You say that a plan representative told you that you could have 
dental care performed by any provider you chose. The Plan denied your request. The Plan says the provider in 
this case is not part of the Plan's dental network. Out-of-network dental care is not covered by this 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. The Plan says that 
supplemental preventative and supplemental comprehensive dental benefits must be obtained from a provider 
in the Plan's dental vendor network. Services obtained from vendors outside this network are not covered. 
Though the Plan offers a dental benefit in excess of Medicare coverage items or services received from out-of-
network providers are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the partial upper denture (D5213) and partial lower denture (D5214) provided on October 1, 
2021.  
 
Your complaint about potential misinformation from a Plan representative 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 crown (D2740) provided on November 4, 2021. 
 
You asked the Plan to pay for the crown. You say that your plan states that crowns are 100% covered as well as 
x-rays and cleanings. You also say that this procedure should be 100% covered as stated in your plan. The Plan 
denied your request. The Plan says the benefit maximum for the 2021 Plan year has been reached and no 
further payment will be made for dental services. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on October 21, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the crown (D2740) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on October 18, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that the x-rays you received were the 
same x-rays that they have been doing for you for more than 20 years. You also say that they were not 
additional or special x-rays. 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 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 first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and resin-based composite (D2393) provided on October 4, 2021 by an out-
of-network (OON) provider. 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
resin-based composite. You say that you saw an OON provider because you were experiencing a lot of pain on 
your tooth. You also say that the dentist wanted to pull the tooth, but you wanted to save it. The Plan denied 
your request. The Plan says these services were rendered by an OON provider. The Plan also says that you 
must receive services at a participating 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite 
(D2393) provided on October 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), implant supported crown (D6066), and bone replacement graft 
for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, implant supported 
crown, and bone replacement graft. You say that you are unable to chew food correctly and already have 
missing teeth next to this implant. The Plan denied your request. The Plan says these services are not covered 
benefits 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 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 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), implant 
supported crown (D6066), and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate 
(conscious) sedation/analgesia  each subsequent 15-minute increment (D9243) provided September 16, 2021, 
and the provided September 23, 2021. 
 
You asked the Plan to pay for the limited oral exam and intravenous moderate sedation. You say that you don't 
understand why the Plan has denied these necessary services. 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 
limited oral evaluation - problem focused (D0140) and intravenous moderate (conscious) sedation/analgesia- 
first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia  each subsequent 15-
minute increment (D9243) provided September 16, 2021, and the provided September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) provided on 
October 21, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedure. You say that you are missing 6 teeth and 
needed the partial. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
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. The record shows that you were informed that this procedure may not 
be covered by your benefit plan, and you had accepted financial responsibility in writing. Therefore, we 
decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) provided on 
October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontic (D6245)
provided on November 10, 2021.
You asked the Plan to pay for the fixed bridge. You say that you have dental coverage. You also say that you
do not understand what good your insurance is if nothing is covered. The Plan denied your request. The Plan
says the fixed bridge is not listed as 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the fixed bridge is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns
(D6740 x 2) and pontic (D6245) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology consultation and report on referred slides 
provided on July 1, 2021, billed with code 88321-91. 
 
You asked the Plan to pay for the consultation and report as billed. You say that this should be paid as the 
correct modifier was used to explain why more than one unit is billed. The Plan denied your request. The Plan 
says this code has an absolute date of service limit of 1 unit. As such, one unit has been paid, but the second 
with modifier -91 is denied correctly. 
 
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 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
consultation and report as billed have not been met. Therefore, we decided that the Plan does not have to pay 
for the pathology consultation and report on referred slides provided on July 1, 2021, billed with code 88321-91.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dental office failed to check with your 
insurance to see if the services would be covered. The Plan denied your request. The Plan says extractions are 
not listed as covered services. 
 
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 extraction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) 
provided on November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the abdomen without 
dye (74181) provided on October 21, 2021. 
You asked the Plan to pay for the MRI without dye. You say that the enrollee had multiple exams provided on 
this date. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between codes 74183 and 74181. This PTP edit has a modifier indicator of 1, 
modifiers associated with NCCI are allowed; however, an appropriate NCCI modifier was not billed with this 
PTP code edit, and therefore this service is denied as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74181 
is a column II code to column I code 74183. 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 magnetic resonance imaging (MRI) of the abdomen without dye 
(74181) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an addition amount for the recement or rebond of crown 
(D2920), bitewing x-rays (D0274), and filling (D2392) provided from July 6, 2021, to September 2, 2021. 
 
You asked the Plan to pay an addition amount for the dental services. You say that you went to an in network 
provider. You say that you are not being told that you owe over $100 combined for the procedures. The Plan 
denied your request. The Plan says 1 set of bitewing x-rays is covered per calendar year. The Plan says the 
frequency limit has been exceeded. The Plan also says that fillings are covered at 50% when received in 
network. 
 
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 bitewing x-rays are listed as covered, the frequency limit of once per calendar year has been exceeded. The record shows that the Plan paid 
for bitewing x-rays that you received on July 6, 2021. The Evidence of Coverage clearly states that you pay 
50% for fillings that you receive in network. This is a contractual obligation you agreed to when you enrolled 
in the Plans dental coverage. Therefore, we decided that the Plan does not have to pay an addition amount for 
the recement or rebond of crown (D2920), bitewing x-rays (D0274), and filling (D2392) provided from July 6, 
2021, to September 2, 2021.