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

 
We decided that the Plan does not have to pre-approve dental crowns (D2751) provided by a participating 
provider. 
 
You asked the Plan to pre-approve dental crowns. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide legible dental x-rays. These x-rays are needed to 
render a decision of medically necessity for D2751. Therefore, we decided that the Plan does not have to pre-
approve dental crowns (D2751) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coronectomy (D7251) and deep sedation (D9223) provided 
by an opt-out provider on March 8, 2021. 
 
You asked the Plan to pay for a coronectomy and deep sedation. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the rendered dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
coronectomy (D7251) and deep sedation (D9223) provided by an opt-out provider on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique (CPT code 87481 X 2). 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the medical records submitted do not contain results to support billing more than 3 units of 
Candida species detection. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found the medical records 
submitted do not contain results to support billing more than 3 units of Candida species detection. Therefore, the two (2) remaining units are not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique (CPT code 87481 X 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration  nonresorbable barrier, per 
site, (includes membrane removal) (code D4267) and primary closure of a sinus perforation (code D7261). 
 
You asked the Plan to pre-approve guided tissue regeneration  nonresorbable barrier, per site,  
(includes membrane removal), and primary closure of a sinus perforation. You say that the dental services are 
medically necessary. The Plan denied your request. The Plan says that the requested dental services are not 
covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration  nonresorbable barrier, per site, (includes membrane removal) (code D4267) and 
primary closure of a sinus perforation (code D7261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 9, 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 service 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 the dental 
services on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was a dental emergency and your provider 
felt it was necessary to begin treatment. 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 March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), intraoral periapical first x-ray (D0220), intraoral periapical each additional x-ray (D0230) and 
bitewings (D0274) provided on March 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought your provider was in-network and 
these services would be covered. The Plan denied your request. The Plan says the dental services were either 
received from an out-of-network provider or 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. Additionally, D0220, D0230 and D0274 are not 
among those covered under your dental plan in any circumstance. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), intraoral periapical first x-
ray (D0220), intraoral periapical each additional x-ray (D0230) and bitewings (D0274) provided on March 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the dental services provided from 
June 13, 2022, to June 20, 2022.  
 
You asked the Plan to increase the reimbursement for the dental services. You say that you should have been 
reimbursed $721. The Plan denied your request. The Plan says your annual dental benefit has been met. 
 
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 only covers dental services up 
to $750 every year. The record shows your annual dental benefit has been exhausted. Therefore, we decided 
that the Plan does not have to increase the reimbursement for the dental services provided from June 13, 2022, 
to June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) and a guided tissue 
regeneration (D4266) provided by a participating provider. 
 
You asked the Plan to pre-approve gingival irrigation and a guided tissue regeneration. You say that these 
services are medically necessary. The Plan denied your request. The Plan says the requested 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 pre-approve 
gingival irrigation (D4921) and a guided tissue regeneration (D4266) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of implant body (D6100) provided 
by a participating provider. 
 
You asked the Plan to pre-approve the surgical removal of implant body. You say that this dental work is 
medically necessary. The Plan denied your request. The Plan says the requested 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 pre-approve the 
surgical removal of implant body (D6100) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a panoramic x-ray (D0330) provided on 
July 5, 2022. 
 
You asked the Plan to waive the deductible for an x-ray. You say that you were told there was no copayment 
for the x-ray. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible that applies to class 2 basic services, which includes 
a panoramic x-ray. 
 
The item or service you asked the Plan to waive the deductible for falls within the dental services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 
deductible which applies to a panoramic x-ray. This cost sharing is a contractual obligation that had not been met at the time an x-ray was received on July 5, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for a panoramic x-ray (D0330) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft first site in quadrant (D4263) 
provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want to know if any part of the bone graft 
would be covered. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows an extraction was 
performed on the same date of service making this service excluded from coverage under your dental benefit. 
Therefore, we decided that the Plan does not have to pay for the bone replacement graft first site in quadrant 
(D4263) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a complete mandibular denture. You say that you would like these services 
covered. The Plan denied your request. The Plan says the requested dental service 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 pre-approve a 
complete mandibular denture (D5120) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of implant body (D6100) and a cartilage 
graft (D7950) for tooth #19 provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that with the proper codes the claim should be 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the surgical removal of implant body and the cartilage graft 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 pay for the 
surgical removal of implant body (D6100) and a cartilage graft (D7950) for tooth #19 provided on April 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a palliative (emergency) treatment of dental pain (D9110) 
provided on August 1, 2022. 
 
You asked the Plan to pay for a palliative (emergency) treatment of dental pain (D9110). You say that the 
emergency dental assistance you received from this provider was on account of a true emergency. You also say 
you had a bacterial infection raging beneath tooth number 19. The Plan denied your request. The Plan says the 
enrollee did not purchase the optional enhanced package. The Plan also says that a palliative (emergency) 
treatment of dental pain (D9110) is not listed as a payable code for the mandatory dental coverage. 
 
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 
palliative (emergency) treatment of dental pain (D9110) provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedure 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 the date of service of February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 14, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal 
epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the injection is not necessary. 
 
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 service. Our physician reviewer 
found the enrollee has a right-sided synovial cyst at L4-L5 that is likely contributing to most of their symptoms 
of right lower extremity pain. The review has determined that the TESI, in combination with the facet joint 
injections, was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pre-
approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483).  
 
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) and does not have to pay 
more for a periapical x-ray (D0220), endodontic therapy on tooth #13 (D3320), and a prefabricated post and 
core on tooth #13 (D2954) provided on June 14, 2022. 
 
You asked the Plan to pay for an evaluation and does not have to pay more for an x-ray, endodontic therapy, 
and a prefabricated post. You say that you disagree with the processing of this claim. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a limited oral evaluation was exhausted on date of service April 27, 2022. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 14, 2022. 
 
You have been asked to pay 50% coinsurance of the allowed amount for endodontic therapy and a 
prefabricated post. You have also been asked to pay the difference between the out-of-network providers 
charges and the Plans payment.  
 
Code Billed Amount Allowed Amount 50% Coinsurance Total Cost Share 
D0220 $35 $10  $25 
D3320 $770 $351 $175.50 $594.50 
D2954 $300 $128 $64 $236 
 
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 periapical x-ray (D0220), endodontic therapy on tooth 
#13 (D3320), and a prefabricated post and core on tooth #13 (D2954) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a limited oral 
evaluation (D0140) provided by an out-of-network provider on July 13, 2022, and July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to help pay for these 
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 February 28, 2022, and a 
June 17, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a limited oral evaluation (D0140) provided by an out-of-network provider on July 13, 2022, and 
July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery procedure (41899) provided by an opt-
out provider. 
 
You asked the Plan to pre-approve dental surgery procedure. You say that you need to see this provider to get 
oral surgery. The Plan denied your request. The Plan says the requested provider has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve 
dental surgery procedure (41899) provided by an opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraorifice barrier (D3911), a cone beam CT capture 
(D0381), and a post removal (D2955). 
 
You asked the Plan to pre-approve an intraorifice barrier, a cone beam CT capture, and a post removal. You 
say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the 
requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
intraorifice barrier (D3911), a cone beam CT capture (D0381), and a post removal (D2955).