Persius/hicric huggingface dataset:
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 November 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had to go to the 
dentist because you fell on your face. You also say that you needed to go for repeat visits because you had 
bleeding and an infection. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on October 11, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with field of view of both jaws (D0383) provided on November 5, 2021. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that the provider said the risk to the 
patient from x-ray exposure is very low using this x-ray as opposed to using conventional x-ray equipment. 
You also say that the provider said the cost of this x-ray is $220 and the cost to use the conventional x-ray 
equipment would cost $800. The Plan denied your request. The Plan says this service is not a covered benefit 
under the enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) image capture with field of view of both jaws (D0383) provided on 
November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2330) provided on September 1, 2021. 
 
You asked the Plan to pay for the filling. You say that this provider is part of the Plan's network, and there are 
previous paid claims from this plan for this provider. The Plan denied your request. The Plan says the provider 
in this case was out-of-network from August 18, 2021, through October 20, 2021. Out-of-network dental care 
is not covered by this Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not pay for out-
of-network dental care. 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-
network providers are not among those covered under this benefit. The record indicates that the provider in this 
case was not part of the Plan's network on the date in question. Therefore, we decided that the Plan does not 
have to pay for the filling (D2330) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on December 7, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you had to go back because you were still 
having pain. You say that you should not have to pay for the second visit. The Plan denied your request. The 
Plan says the benefit limit for D0140 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 limited oral 
evaluation per calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a limited oral evaluation was 
provided on November 3, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) provided by a participating provider on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 8, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you did not know that your decision to 
opt-out of Medicare would impact payment for non-Medicare covered services. The Plan denied your request. 
The Plan says the provider in this case does not participate in Original Medicare, and therefore these services 
are ineligible for payment. 
 
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 requires dental care 
to be performed by a provider who accepts Medicare patients in the United States and has not opted out of 
Original Medicare. We looked at the file and the Plan's rules. The provider in this case does not participate in Original Medicare. 
Based on this information, we decided that the Plan's rules for coverage of supplemental dental services are not 
met. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided 
on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic 
imaging (D0220 and D0230), and an unspecified preventative procedure (D1999) provided by a participating 
provider on December 7, 2021, and December 14, 2021. 
 
You asked the Plan to pay for dental services. You say that you were in pain and needed to see a dentist. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic imaging (D0220 and D0230), and an unspecified preventative procedure (D1999) provided by a participating provider on December 7, 2021, and December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 29, 2021, by 
the out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that none of the dentists in network are capable of 
providing the continuity of care appropriate. The Plan denied your request. The Plan says you pay 100% for 
dental services received out of network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the prophylaxis is not among those 
covered under this benefit when received out of network. Therefore, we decided that the Plan does not have to 
pay for the prophylaxis (D1110) provided on November 29, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillofacial prosthesis (D5999), core buildup, including 
any pins when required (D2950), and indirect pulp cap (D3120) provided on October 18, 2021. 
 
You asked the Plan to pay for the maxillofacial prosthesis, core buildup, and indirect pulp cap. You say that 
you feel that you were charged for work that was not performed. The Plan denied your request. The Plan says 
the maxillofacial prosthesis is not covered under your dental plan. The Plan also says that there is a limit for 
how often a core buildup and indirect pulp cap can be covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, unspecified maxillofacial prosthesis 
(D5999) is not among those covered under this benefit. The contract says that core buildup, including any pins 
when required (D2950) and indirect pulp cap (D3120) are each limited to 1 per year. The record shows that you 
received two core buildups, including any pins when required (D2950 x2) and two indirect pulp caps (D3120 
x2) on October 18, 2021, one of each were covered by the Plan, and your core buildup, including any pins 
when required (D2950) and indirect pulp cap (D3120) benefits have been exhausted. Therefore, we decided 
that the Plan does not have to pay for the maxillofacial prosthesis (D5999), core buildup, including any pins 
when required (D2950), and indirect pulp cap (D3120) provided on October 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you are losing your eyesight and you need 
to make an appointment to keep from going blind. The Plan denied your request. The Plan says you are 
requesting an additional 32 miles for a total of 82 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99225) provided August 15, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee had elected their hospice benefit at the time service was 
rendered and Original Medicare is liable for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services (99225) provided August 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alginate or other fiber gelling dressing (A6197) and 
Hydrogel dressing (A6248). 
 
You asked the Plan to pre-approve Alginate or other fiber gelling dressing (A6197) and Hydrogel dressing 
(A6248). You say that the requested Alginate or other fiber gelling dressing (A6197) and Hydrogel dressing 
(A6248) are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested Alginate or other fiber gelling dressing (A6197) and Hydrogel dressing (A6248). 
 
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 Alginate or other fiber gelling dressing 
(A6197) and Hydrogel dressing (A6248). Our reviewer says that the enrollee does not meet criteria for the 
requested Alginate or other fiber gelling dressing (A6197) and Hydrogel dressing (A6248). Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee meets the 
above Local Coverage Determination criteria for the requested Alginate or other fiber gelling dressing (A6197) 
and Hydrogel dressing (A6248). Records do not provide any up-to-date documentation of the stage or nature of 
the wound in this case; the latest records available are from April 21, 2021. An up-to-date assessment of the 
wound including the wound stage and presence, or absence of exudate would be needed to determine LCD 
criteria for 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 Alginate or other fiber gelling dressing (A6197) and Hydrogel dressing (A6248) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Alginate or other fiber 
gelling dressing (A6197) and Hydrogel dressing (A6248).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided January 4, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services were medically 
necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with 
another code 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 71045 
is a column II code to column I code 74022. 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 radiology services (71045) provided January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on January 12, 2021, and July 20, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you feel like the Plan should pay for this. 
The Plan denied your request. The Plan says the benefit limit for D0140 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 two limited 
oral evaluation per calendar year.  
We looked at the file and Medicare rules. Evidence was provided to show that all services provided on January 
12, 2021, and February 1, 2021, were approved and paid. Therefore, D0140 provided on March 16, 2021, and 
July 20, 2021, have been correctly denied. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) provided by a participating provider on January 12, 2021, and July 
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided by a participating 
provider on December 15, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you believe these should be covered. The 
Plan denied your request. The Plan says the benefit limit for D2391 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 two resin-
based composites per calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the benefit limit for D2391 was 
exhausted on July 26, 2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have already been met. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2391) provided by a participating provider on December 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services 
identified. The documentation does not support that it is medically reasonable and necessary to provide the 
enrollee with skilled services on a daily basis. As a practical matter, the enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 1, 2021, to October 2, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the self-administered drugs were denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from October 1, 2021, to October 2, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laughing gas (D9230) provided on October 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need the laughing gas to be covered. You 
also say that you have high blood pressure. The Plan denied your request. The Plan says laughing gas 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 laughing gas is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the laughing gas 
(D9230) provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoplasty in conjunction with extractions (D7311) 
provided by a participating provider on November 2, 2021. 
 
You asked the Plan to pay for an alveoplasty in conjunction with extractions. You say that these services were 
necessary after you had the extractions done. The Plan denied your request. The Plan says D7311 is not a 
covered 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 an 
alveoplasty in conjunction with extractions (D7311) provided by a participating provider on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) or pay for the 
prophylaxis (D1110) provided on December 15, 2021. 
 
You asked the Plan to pay more for the periodic oral evaluation and to pay more for the prophylaxis. You say 
that you feel these services should be covered because you are allowed two cleanings per year. The Plan denied 
your request. The Plan says you have exceeded the benefit period program maximum. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on while processing this claim 
for the December 15, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) or pay for the 
prophylaxis (D1110) provided on December 15, 2021.