Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health care provided 
from October 27, 2021, to November 3, 2021. 
 
You asked the Plan to waive the copayments for outpatient mental health care. You say that you thought that 
you would not owe anything for the services and if you had known, you would not have received the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person visits with a clinical psychologist and $30 for each telehealth visit with a clinical 
psychologist. 
 
You received outpatient mental health care in-person with a clinical psychologist on October 27, 2021. 
Therefore, you are responsible to pay the $35 copayment.  
 
You had a telehealth visit with a clinical psychologist on November 3, 2021. Therefore, you are responsible to 
pay the $30 copayment. 
 
The total amount you owe is: $65.  
 
You have been asked to pay the total copayment amount of $65 for outpatient mental health care. Outpatient 
mental health care falls within the outpatient mental health care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. 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 waive the copayments for outpatient mental health care provided from October 27, 2021, to November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210), periodontal 
scaling and root planing of four or more teeth per quadrant (D4341), periodontal scaling and root planing of 
one to three teeth per quadrant (D4342), two gingival irrigations (D4921 x2), and two drugs or medicaments 
dispensed in the office for home use (D9630 x2) provided on November 18, 2021, and November 26, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays, scalings and planings, gingival irrigations, 
and drugs or medicaments. You say that you needed the scalings and planings done to be able to get the partial. 
The Plan denied your request. The Plan says these services are not covered expenses 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 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 
complete series of intraoral x-rays (D0210), periodontal scaling and root planing of four or more teeth per 
quadrant (D4341), periodontal scaling and root planing of one to three teeth per quadrant (D4342), two 
gingival irrigations (D4921 x2), and two drugs or medicaments dispensed in the office for home use (D9630 
x2) provided on November 18, 2021, and November 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8. 
 
You asked the Plan to pre-approve the crown. You say that your dentist advised that a crown is medically 
necessary. The Plan denied your request. The Plan says this service is only covered 1 time in a 60-month 
period. The Plan also says that you had a crown on tooth #8 completed on February 3, 2020. 
 
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, crown (D2751) and is limited to 1 per 
60 months per tooth. The record shows that you received a crown on tooth #8 on February 3, 2020 and your 
crown (D2751) benefit for tooth #8 has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve a crown (D2751) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general dental visit(s) to be rendered by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the general dental visit(s). You say that you would like to see this OON 
provider because your teeth are very sensitive. The Plan denied your request. The Plan says this out of network 
service is not medically necessary. The Plan also says that the medically necessary services are available in 
your area with participating providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve 
general dental visit(s) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on November 15, 2021. 
 
You asked the Plan to pay for the limited exam. You say that you were referred to another provider for your 
issue, and this service was necessary. The Plan denied your request. The Plan says you had a previous limited 
oral exam on November 4, 2021, which was covered and paid for at that time. Your dental benefit covers one 
limited oral exam per plan year. 
 
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 can cover one 
limited exam to evaluate a problem (D0140) per plan year. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the limited oral exam (D0140) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core buildup (D2950) and oral/facial 
photographic image (D0350) provided on September 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not realize that crowns were no longer 
covered by your Plan. The Plan denied your request. The Plan says these services are not covered by your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740), core buildup (D2950) and oral/facial photographic image (D0350) provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telomerase reverse transcriptase gene analysis, targeted 
sequence analysis (81345) provided on September 8, 2021. 
 
You asked the Plan to pay for code 81345. 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 81345 
is a column II code to column I code 0089U. 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 telomerase reverse transcriptase gene analysis, targeted 
sequence analysis (81345) provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6066). 
 
You asked the Plan to pre-approve the implant supported crowns. You say that you received a letter from your 
primary care physician stating these procedures are required. The Plan denied your request. The Plan says this 
service is 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 
implant supported crowns (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs this service in order for 
their dentures to fit more comfortably. The Plan denied your request. The Plan says removal of torus 
mandibularis 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of torus 
mandibularis is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removal of torus mandibularis (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of shoulder dislocation, with 
manipulation (23650) billed with the assistant at surgery modifier provided on October 15, 2021. 
 
You asked the Plan to pay for the closed treatment of shoulder dislocation. You say that you would like this 
claim reprocessed as there was a network insufficiency regarding in-network providers. The Plan denied your 
request. The Plan says this claim is not eligible for payment when billed with an assistant at surgery modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that if the Medicare Fee 
Schedule Database contains an assistant at surgery indicator of 1 for the surgical procedure in question, 
Medicare has determined that an assistant is not medically necessary  
 
We find that CPT code 23650 has an assistant at surgery indicator of 1 in the Medicare Fee Schedule Database. 
Based on this information, we decided that Medicare rules for coverage of the closed treatment of shoulder 
dislocation have not been met. Therefore, we decided that the Plan does not have to pay for the closed 
treatment of shoulder dislocation, with manipulation (23650) billed with the assistant at surgery modifier 
provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 7, 19, 20, and 
29 and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243 x3). 
 
You asked the Plan to pre-approve the surgical extractions and intravenous moderate (conscious) 
sedation/analgesia. You say that the enrollee is very uncomfortable, finds it hard to bite, and is having trouble 
eating. You also say that the enrollee has a cracked tooth which is cracked in the front, is loose, and makes it 
hard to bite. The Plan denied your request. The Plan says these 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 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 only type of extractions that are covered under the enrollee's plan 
are simple extractions. Therefore, we decided that the Plan does not have to pre-approve surgical extractions 
(D7210) of tooth #'s 7, 19, 20, and 29 and intravenous moderate (conscious) sedation/analgesia (D9239 and 
D9243 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) of tooth #14, two 
anterior resin-based composites of one surface (D2330 x2), two posterior resin-based composites of one surface 
(D2391 x2), or pay more for the first intraoral periapical x-ray (D0220) of tooth #19 and posterior resin-based 
composite of two surfaces (D2392) provided from June 1, 2021, to September 14, 2021 by an out-of-network 
(OON) provider. 
You asked the Plan to pay for the first intraoral periapical x-ray of tooth #14, anterior resin-based composites 
of one surface, posterior resin-based composites of one surface, and to pay more for the first intraoral periapical 
x-ray (D0220) of tooth #19 and posterior resin-based composite of two surfaces. You say that you were told 
that you had a $1,000 credit to use toward dental services. You also say that you would like these services to be 
covered. The Plan denied your request. The Plan says these services were performed by a non-participating 
provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the 
provider bills you for the services. The Plan also says that your intraoral x-rays and restorations benefits have 
been satisfied and the frequency limitations have been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure code per calendar year. The record shows that you received two first intraoral periapical x-rays 
(D0220 x2) on June 1, 2021, one of which was covered by the Plan, and your intraoral x-rays benefit has been 
exhausted. The contract also says that restorations are limited to two procedure codes per calendar year. The 
record shows that you received resin-based composites (D2330 and D2392) on April 29, 2021, and June 14, 
2021 and your restorations benefit has been exhausted. You are also responsible for the difference between the 
billed amounts and allowed amounts for covered dental services that are received OON. Therefore, we decided 
that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) of tooth #14, two anterior 
resin-based composites of one surface (D2330 x2), two posterior resin-based composites of one surface (D2391 
x2), or pay more for the first intraoral periapical x-ray (D0220) of tooth #19 and posterior resin-based 
composite of two surfaces (D2392) provided from June 1, 2021, to September 14, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the extraction (D7140) provided on 
November 1, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you thought you had dental 
insurance to help you have healthy teeth. You say that you feel you should not have humongous bills while 
being on an extremely limited income. The Plan denied your request. The Plan says you pay 50% for 
extractions that you receive in network. 
 
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 and extractions are listed as covered, 
there is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the 
Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the 
extraction (D7140) provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100) provided on June 9, 2021. 
 
You asked the Plan to pay for code 99100. 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. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, 
expandable controller harness and a power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it 
is not primarily medical in nature. 
 
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 an expandable controller, electronic 
connection and expandable controller harness. Our reviewer says that an expandable controller, electronic 
connection and expandable controller harness are not considered medically reasonable and necessary in this 
case. This request exceeds the patient's medical need. The patient does not require non-proportional input 
devices. The patient does not require a separate display, other electronic devices, or an attendant control. The 
patient has 2 power options of tilt, and power elevating leg rests on the approved wheelchair but the patient 
does not need to control the power options through a joystick. The patient's right upper extremity strength and 
function support that the patient can control any power options through their own switches. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller, electronic connection, expandable controller harness and a 
power seat elevation feature for the enrollee.
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 three 
additional intraoral periapical x-rays (D0230 x3) provided on November 17, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that according to the 2021 Evidence of 
Coverage, both first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) are 
fully covered by your plan. The Plan denied your request. The Plan says these services are not covered benefits 
under your dental plan. The Plan also says that you are not enrolled in the supplemental dental rider. 
 
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 three additional intraoral periapical x-rays (D0230 x3) provided on 
November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown to be rendered by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the crown. You say that you had work done over the crown, which was a 
bad root canal, it was done improperly. You also say that if you lose this tooth you will have to get an implant 
which is medically necessary to chew. The Plan denied your request. The Plan says you received a crown on 
tooth #28 on February 19, 2019. The Plan also says that this service is available in-network when the benefit 
becomes available. 
 
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 
covered when they are received OON. The contract also says that crowns are limited to 1 per 60 months. The 
record shows that you received a crown on tooth #28 on February 19, 2019 and your crown benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown to be rendered by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), topical 
application of fluoride varnish (D1206), intraoral - periapical first radiographic image (D0220), and intraoral - 
periapical each additional radiographic image (D0230) provided October 20, 2021. 
 
You asked the Plan to pay for the panoramic x-ray, fluoride varnish and intraoral x-rays. You say that you feel 
that the x-rays should be covered. 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 panoramic radiographic image (D0330), topical application of fluoride varnish (D1206), intraoral - periapical 
first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) 
provided October 20, 2021.