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

 
We decided that the Plan does not have to provide additional payment for the maxillary partial denture - 
flexible base (including any clasps, rests and teeth) (D5225) provided December 17, 2021. 
 
You asked the Plan to provide additional payment for the upper partial denture. You say that you see no reason 
why the service wasn't paid in full. The Plan denied your request. The Plan says you have reached your benefit 
maximum and no further payment is due. 
 
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 upper 
partial denture up to a $2,000 annual maximum. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $983 remaining in your annual maximum. This amount was applied to the service.  
You have been asked to pay the remaining amount over your annual maximum. Therefore, we decided that the 
Plan does not have to provide additional payment for the maxillary partial denture - flexible base (including 
any clasps, rests and teeth) (D5225) provided December 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on December 7, 
2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that there is an authorization on file for these 
physical therapy services. The Plan denied your request. The Plan says they have agreed to pay for the physical 
therapy services (97530, 97110, G0283); however, the payment for hot or cold packs therapy is always 
included in the payment for another service. Code 97010 has a status indicator of B, which means this service 
is not separately payable. 
 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 find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
January 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not have had these services done if 
you knew they would not be covered. You say that you are on a fixed income. You also say that you would not 
be able to pay these charges all at one time. The Plan denied your request. The Plan says the services were 
denied correctly. 
 
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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says IRF is not medically necessary and the enrollee's needs can be met at a lower level of care such as at a skilled nursing facility, on an intermittent basis at home with home health care, or in a long-term acute care setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 18, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on June 1, 2021. 
 
You asked the Plan to pay for code 87798. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 87798. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that when reporting an 
"unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in claim 
form item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment 
shall be submitted with the claim. 
 
In this case, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this is a not otherwise 
classified procedure code that was not reported with a narrative description of the code in item 19 of the claim 
or in an attachment. Based on this information, we decided that Medicare rules for coverage of code 87798 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 
provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair resin partial denture base, mandibular (D5611) 
provided September 3, 2021. 
 
You asked the Plan to pay for the repair lower resin partial denture base. You say that you believe this service 
should be covered. 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 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 repair 
resin partial denture base, mandibular (D5611) provided September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0272) provided on December 23, 2021, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were told you had 
dental coverage. The Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays the provider. Therefore, 
we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0272) provided on December 23, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided January 3, 2022. 
 
You asked the Plan to pay for the complete series of x-rays. You say that when you went to the dentist, they did 
not inform you that they were not in the Plan's network. The Plan denied your request. The Plan says this 
service is not covered because it was provided OON. 
 
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 complete 
series of x-rays when you use a provider that is contracted with the Plan's dental vendor to provide 
supplemental dental services. 
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the complete series of x-rays have not been met. Therefore, we decided that the Plan does not have to pay for 
the intraoral - complete series of radiographic images (D0210) provided January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Colpopexy (57282) provided on December 13, 2021. 
 You asked the Plan to pay for code 57282. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 57282 
is a column II code to column I code 58291. 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 the Colpopexy (57282) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751) for tooth # 12, and pontic 
(D6241) for tooth # 13. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you need this service. You say that you have a 
missing front tooth. The Plan denied your request. The Plan says the requested bridge is not medically 
necessary. 
 
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 a fixed bridge 
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 a fixed bridge. Our reviewer says 
that the requested fixed bridge does not meet the criteria for coverage. Our physician reviewer found the plan 
criteria indicates that coverage for a fixed bridge when to replace a single maxillary anterior tooth or two 
adjacent mandibular anterior teeth. The reviewer found that the documentation indicates multiple missing 
posterior maxillary teeth including tooth # 13. Therefore, the reviewer found that the requested service does not 
meet the criteria for coverage. 
 
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 a fixed bridge have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a retainer crown (D6751) for tooth # 12, and pontic (D6241) for tooth # 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided December 15, 2021. 
 
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you need to see the 
dentist three times per year because you have diabetes. The Plan denied your request. The Plan says you have 
exceeded the frequency limits for these 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. The Plan covers the periodic 
oral exam and dental cleaning twice per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral exam 
and dental cleaning were previously covered on April 21, 2021, and August 18, 2021. Based on this information, 
we decided that the Plan's frequency limits for coverage of the periodic oral exam and dental 
cleaning have been exceeded. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a splint - extra-coronal; natural teeth or prosthetic 
crowns (D4323). 
 
You asked the Plan to pre-approve a tooth splint. You say that you are in a lot of pain and want to be proactive 
in saving your tooth. 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 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 
splint - extra-coronal; natural teeth or prosthetic crowns (D4323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140) provided by a participating provider on 
November 29, 2021. 
 
You asked the Plan to pay for extractions. You say that you were in a lot of pain. You say that it would have 
cost more to go to the emergency room. The Plan denied your request. The Plan says this claim has been 
correctly denied. 
 
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 
extractions (D7140) provided by a participating provider on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and bone 
replacement graft for ridge preservation - per site (D7953) provided January 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the guided tissue regeneration, tooth extraction and bone replacement graft. You 
say that you had no knowledge that you should have requested an exception to see an OON provider. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON without 
prior authorization. 
 
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 guided tissue regeneration, tooth extraction and bone replacement graft when rendered by a participating provider.  
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the guided tissue regeneration, tooth extraction and bone replacement graft have not been met. Therefore, we 
decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and bone 
replacement graft for ridge preservation - per site (D7953) provided January 27, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2020. 
 
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 services are not separately payable. 
 
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 87150 is a column II code to column I code 87500. Codes 87481, 
87491, 87591, 87640, 87641, 87653, and 87798 are column II codes to column I code 87150. The column II 
codes were not billed with an appropriate modifier to bypass the edit. The -59 modifier is not supported as a 
separate and distinct procedural service for these codes based on the submitted documentation. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950) for tooth #29 
provided by a participating provider on February 2, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that due to decay of the crown, a new 
crown is needed. The Plan denied your request. The Plan says the benefit limit for the rendered dental services 
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. The Plan covers a crown and a 
core build-up once per lifetime per tooth. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2740 was provided on 
December 13, 2019. Based on this information, we decided that the Plan's rules for coverage of a crown and a core build-up have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740), and a core build-up (D2950) for tooth #29 provided by a participating provider on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on January 11, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that your previous provider was unable to provide the treatments you needed, which resulted in you having 
to change dentists. You also say that this treating dentist did the right thing to insist on repeating these services, 
because he did not have anything else to go by. The Plan denied your request. The Plan says these services 
exceed the frequency limitations in 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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on November 17, 2020 and your comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) provided on January 11, 2022.