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

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown (D2750) 
Tooth #12, false tooth for bridge (D6240) Tooth #19 and 3, white glass with high gold content cap for bridge 
(D6750) Tooth #1, 2, 3, 4, 5, 18 and 20. 
 
You asked the Plan to pre-approve dental services. You say that you are having problems with your upper 
teeth, and you cannot afford to pay these services if they are not covered. The Plan denied your request. The 
Plan says upon review of the X-rays provided, the criteria for coverage were not 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. The Plan covers dental 
services when the services are medically necessary and reasonable. The contract says that the Plan covers 
certain dental services as a supplemental (extra) benefit. This benefit includes white glass with high gold 
content crown (D2750), false tooth for bridge (D6240) and white glass with high gold content cap for bridge 
(D6750) but each are limited to one per 60 months. 
 
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 dental services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the documentation provided does not 
meet the criteria for fixed bridges replacing missing teeth #'s 3 and 19. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered white glass with 
high gold content crown (D2750) on May 20, 2019. Therefore, this benefit was exhausted. Therefore, we 
decided that the Plan does not have to pre-approve. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve false tooth for bridge (D6240) Tooth #19 and 3, white glass with high gold content cap for 
bridge (D6750) Tooth #1, 2, 3, 4, 5, 18 and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT capture and interpretation with field of 
view of both jaws; with or without cranium (D0367), guided tissue regeneration - resorbable barrier, per site 
(D4266), bone replacement graft for ridge preservation - per site (D7953), and primary closure of a sinus 
perforation (D7261). 
 You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of requested 
services. The Plan denied your request. The Plan says sinus perforation (D7261) is a covered benefit, however, 
a sinus perforation which might occur cannot be determined in advance. Therefore, D7261 is 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. The Plan covers dental 
services when the services are medically necessary and reasonable. This benefit includes primary closure of a 
sinus perforation (D7261) but is limited to one D7260 or D7261 per lifetime. Cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium (D0367), guided tissue regeneration - 
resorbable barrier, per site (D4266) and bone replacement graft for ridge preservation - per site (D7953) are not 
covered under the Plans dental benefits. 
 
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 dental services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the repair of a sinus perforation is not 
necessary at this time as it cannot be determined that there will in fact be a sinus perforation upon removal of 
the tooth. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0367, 4266 and 7953 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve cone beam CT capture and interpretation with field of view of both jaws; with or without cranium 
(D0367), guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge 
preservation - per site (D7953). 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve, and primary closure of a sinus perforation (D7261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on January 13, 2023. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that asdf The Plan denied 
your request. The Plan says procedure code D4381 is not in the list of covered procedures 
 
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 localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 
(D4381) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 12, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the evaluation was medically necessary and 
should be paid in full. 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 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral radiographic 
image (D0220), a cone beam (D0364), pulp vitality tests (D0460), and endodontic therapy (D3330) for tooth 
#19 provided on January 17, 2023, and January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain, so you had to see a 
specialist. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the limited oral evaluation, intraoral radiographic image, a cone beam, pulp vitality tests, and 
endodontic therapy 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 a limited 
oral evaluation (D0140), intraoral radiographic image (D0220), a cone beam (D0364), pulp vitality tests 
(D0460), and endodontic therapy (D3330) for tooth #19 provided on January 17, 2023, and January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that the requested provider is closer to 
your home than in-network providers. The Plan denied your request. The Plan says these items are available 
from in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diabetic shoes and inserts to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 5, 2021, 
through November 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was transferred from an outside facility on November 5, 2021 with respiratory failure 
secondary to Covid pneumonia. She was treated initially with a continuous positive airway pressure (CPAP) 
device but required intubation and mechanical ventilatory support from November 5, 2021, through  
November 15, 2021. She was also treated with intravenous steroids, antibiotics, and Remdesivir. Her condition 
stabilized and improved and she was discharged when considered medically stable on November 23, 2021. 
The review has determined that the record showed that at the time of the inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from November 5, 2021, through November 23, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and trigger point injections billed with codes 
99214, 20553, and J2001 for June 29, 2022, by an out-of-network (OON) provider. 
 
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 rendered by a non-network provider without prior authorization and 
code J2001 is not separately payable. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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.  
 
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 J2001 
is a column II code to column I code 20553. 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 office visit and trigger point injections billed 
with codes 99214, 20553, and J2001 for June 29, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain fused to predominantly base metal 
(D2751) provided on December 15, 2022. 
 
You asked the Plan to pay for dental services. You say that you thought the service was covered because your 
card states you have dental coverage. You say you are on a fixed income and cannot afford extra expenses. The 
Plan denied your request. The Plan says this service is not covered under your 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. Crown - porcelain fused to 
predominantly base metal (D2751) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2751 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown - porcelain 
fused to predominantly base metal (D2751) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - three surfaces, posterior 
(D2393) provided on December 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the billed service should be covered in 
full. 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. 
 
  The allowed amount of the covered dental service total $95, resulting in a coinsurance amount of $19 and a 
Plan payment amount of $76. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
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 resin-based composite - three surfaces, posterior (D2393) 
provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
panoramic radiographic image (D0330) provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the services paid for by your 
insurance because they were needed to determine the most suitable procedure. 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. This benefit includes the 
requested limited oral evaluation - problem focused but is limited to one procedure code per calendar year and 
panoramic radiographic image but is limited to one procedure code every five calendar years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered limited oral evaluation - problem focused (D0140) on January 16, 2023, and 
intraoral - complete series of radiographic images (D0210) on November 14, 2019. Although D0330 and 
D0210 are two different services, they fall within the same category in your Evidence of Coverage and are 
subject to the same frequency limitations. Therefore, these benefits were exhausted as of February 21, 2023. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) 
and panoramic radiographic image (D0330) provided on February 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 24, 
2023. 
 You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service January 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge day management services provided 
on December 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON nursing facility discharge day management services. You say that the 
enrollee was residing at the facility and this provider should not have been responsible for obtaining 
authorization. You say that the assisted living facility is responsible to obtain prior authorization for all their 
patients. The Plan denied your request. The Plan says no medical necessity for OON care has been 
documented. The Plan says that there is no network deficiency for the services in dispute and alternate network 
providers were found who could have supplied the services needed.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. 
Therefore, we decided that the Plan does not have to pay for nursing facility discharge day management 
services provided on December 22, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 24, 
2022, through June 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the case is a retrospective appeal for payment of the acute inpatient hospital care provided 
from May 24, 2022, through June 7, 2022 for a patient presenting with abdominal pain. Very limited medical 
records have been provided in this case; the records provided consist of 14 pages made up of turning and 
positioning reports, pain assessments and vital signs. The provided records do not include any documentation 
of a provider obtained medical history, examination, medical decision making or treatment. The provided 
records do not document that at the time of the inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department (ED) and/or 
observation care) would span two midnights. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from May 24, 2022, through June 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 26, 
2022. 
 You asked the Plan to pay for procedure code 99223. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99223 is bundled into payment for code 
99232. 
 
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 99223 
is a column II code to column I code 99232. 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 procedure code 99223 billed for date of service August 26, 2022.