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

 
We decided that the Plan does not have to pay for the dental services on July 7, 2022, to July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 7, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 7, 2022, to July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation (D0150) and the surgical removal of 
erupted teeth (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you want to appeal the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because dental services are not covered when provided by an oral surgeon. 
 
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 oral surgeon. 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 
oral surgeon. Therefore, we decided that the Plan does not have to pre-approve an oral evaluation (D0150) and 
the surgical removal of erupted teeth (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a retainer crown - porcelain fused to high noble metal tooth #'s 4, 
6 (D6750), and pontic - porcelain fused to high noble metal tooth #5 (D6240). 
 
You asked the Plan to pre-approve the retainer crown - porcelain fused to high noble metal tooth #'s 4, 6 
(D6750), and pontic - porcelain fused to high noble metal tooth #5 (D6240). The Plan denied your request. The 
Plan says the documentation did not meet the clinical criteria for the services requested. 
 
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 the retainer 
crown - porcelain fused to high noble metal tooth #'s 4, 6 (D6750), and pontic - porcelain fused to high noble 
metal tooth #5 (D6240) when the services are medically necessary and reasonable. 
 
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 the retainer crown - porcelain fused to 
high noble metal tooth #'s 4, 6 (D6750), and pontic - porcelain fused to high noble metal tooth #5 (D6240). Our 
reviewer says that placement of a new bridge is medically reasonable and necessary. Our physician reviewer 
found The documentation meets the criteria for a replacement bridge replacing tooth #5 with a pontic (D6240) 
using teeth #'s 4 and 6 as abutment retainers. This treatment is medically reasonable and necessary since teeth 
#4 and #6 require crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crown - porcelain fused to high noble metal tooth #'s 4, 6 (D6750), 
and pontic - porcelain fused to high noble metal tooth #5 (D6240) have been met. Therefore, we decided that 
the Plan has to pre-approve a retainer crown - porcelain fused to high noble metal tooth #'s 4, 6 (D6750), and 
pontic - porcelain fused to high noble metal tooth #5 (D6240).  
 
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 a limited oral evaluation (D0140), an intraoral - periapical 
first radiographic image (D0220), and an extraction of an erupted tooth or exposed root (D7140) provided on 
July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had this procedure done about five years 
ago. You also say that the Plan never gave you information stating that this medical procedure was no longer 
covered. 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, an intraoral - periapical first radiographic image 
(D0220), and an extraction of an erupted tooth or exposed root (D7140) are not covered under this benefit 
when received from an out-of-network provider.  
 
Also, though the Plan offers a dental benefit in excess of Medicare coverage, a limited oral evaluation (D0140) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140), an intraoral - periapical first radiographic image (D0220), and an extraction of 
an erupted tooth or exposed root (D7140) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the endodontic therapy (D3310) for tooth #9. 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and need the dental 
procedure done. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve the endodontic therapy (D3310) for tooth #9.  
 
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 pre-approve a partial denture (D5212). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
partial dentures 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 
partial denture (D5212).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment  includes modification and 
placement tooth #2 (D6056), and implant supported porcelain/ceramic crown tooth #2 (D6065). 
 
You asked the Plan to pre-approve the prefabricated abutment  includes modification and placement tooth #2 
(D6056), and implant supported porcelain/ceramic crown tooth #2 (D6065). The Plan denied your request. The 
Plan says these services are not covered under the 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 
prefabricated abutment  includes modification and placement tooth #2 (D6056), and implant supported 
porcelain/ceramic crown tooth #2 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services provided from April 6, 2022, to 
May 27, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that the plan should make more attempts to 
gather necessary codes to process this case. You also say that you did not continue to try and reach the provider because you thought the plan was doing so. The Plan denied your request. The Plan says there was no itemized 
list of services at issue provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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. 
Specifically, an itemized list of services was not submitted. Without an itemized list of services, it cannot be 
determined if the services are coverable. Therefore, we decided that the Plan does not have to reimburse you 
for the dental services provided from April 6, 2022, to May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920). 
 
You asked the Plan to pre-approve the alignable system. You say that the enrollee's older prosthetic leg is 
failing him and its time to update and replace it to a new microprocessor knee and foot. The Plan denied your 
request. The Plan says the enrollee's current prosthetic socket approved June 2022, includes L5920 and the 
notes do not show that L5920 is damaged beyond repair and cannot be reused for approved socket. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the alignable system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has been an amputee for approximately 8 years due to complications 
from diabetes/vascular insufficiency. These issues are causing the enrollee to feel very unsafe and fearful of 
falling. The enrollee requires a new system and mechanical knee such as the Lynx or C-leg 4 with a Pro-flex 
foot. The current C-leg is out of warranty and doesnt feel safe in it anymore. However, detailed documentation 
is not evident regarding the need for the replacement of L5920. The documentation supports that the current 
system is over 3 years old, and the socket no longer fits properly due to weight/volume fluctuations, and the 
components are worn beyond repair. The documentation does not support that L5920 was worn beyond repair 
and that this could not be used with the approved socket (L5828, L5845, L5848, and L5856). Additionally, the 
requesting provider indicated on the detailed work order that the codes L5828, L5845, L5848, and L5856 were 
needed and did not include the L5920 that was recommended by the prosthetist. Per the Medicare guidelines, 
Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket) must be 
supported by a new treating practitioners order and documentation supporting the reason for the replacement.  
This is not evident in the records provided for review. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the medical records provided do not meet the medically necessary requirements for Medicare 
coverage. 
 
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 alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, alignable 
system (L5920).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular partial denture cast metal framework 
with resin denture bases (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the request is medically necessary. 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 25, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture cast metal 
framework with resin denture bases (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A9279 billed for date of service March 11, 2022. 
 
You asked the Plan to pay for code A9279. You say that this item was medically necessary and approved by 
Medicare. The Plan denied your request. The Plan says code A9279 is not covered. The Plan must follow 
Medicare rules. Medicare rules say that code A9279 is statutorily non-covered. Therefore, we decided that the 
Plan does not have to pay for code A9279 billed for date of service March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), 2D oral/facial photographic image 
(D0350), topical application of fluoride varnish (D1206), adult prophylaxis (D1110), a comprehensive oral 
evaluation (D0150), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each 
additional radiographic image (D0230) provided on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is in 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 bitewings (D0274), 2D oral/facial photographic image (D0350), topical application of fluoride 
varnish (D1206), adult prophylaxis (D1110), a comprehensive oral evaluation (D0150), intraoral - periapical 
first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) 
provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve internal root repair (D3333) for tooth #12 and #31. 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for you to receive 
this service because you are in pain. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because internal root repair is 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 
internal root repair (D3333) for tooth #12 and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgeon services. 
 
You asked the Plan to pre-approve the dental services. You say that there are no in-network oral surgeons 
within 20 miles of your zip code. 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 oral 
surgeon services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. 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 May 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on June 9, 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 05/14/2019. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on June 9, 2022.