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

 
We decided that the Plan does not have to pay for the cone beam CT image capture (D0383) provided on May 
19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this procedure is a covered 
benefit once every five years. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 CT image capture (D0383) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on August 11, 2023 by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you had an appointment with 
the out-of-network dental provider which you have used before with no problems. You are requesting an 
appeal since you pay your premium and were told in the initial phone call that it would not be an issue. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 11, 2023 by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lens gas permeable (V5231) and contact lens 
fitting (92072). 
 You asked the Plan to pre-approve contact lens gas permeable (V5231) and contact lens fitting (92072). You 
say that there were no other lenses currently available that could meet the corrective technical specifications 
required of your left eye. The Plan denied your request. The Plan says Medicare nor the Plan covers this. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that when the PROSE device 
is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531 
(contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325)) and is subject to the 
Medicare refractive lens statutory coverage exclusion. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of contact lens gas permeable (V5231) and contact lens fitting (92072) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve contact lens gas permeable (V5231) and contact lens 
fitting (92072).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle, patient 
weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a Group 1 heavy duty power operated vehicle. You say that you were 
refused the scooter because they have raised the weight requirements, and you were unable to get the larger 
scooter. You also say that when you first tried the smaller scooter about 10 years ago, the durable medical 
equipment company put you on the larger one because you were unable to fit on the smaller one. The Plan 
denied your request. The Plan says according to the clinical documentation, it does not indicate that your 
weight is at least 285 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) is covered if the 
beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater than or 
equal to 95% of the weight capacity of the next lower weight class POV. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 1 heavy duty power operated vehicle have not been met. Specifically, the provided records 
show that your most recent documented weight is below the required weight limit of 301 to 450 pounds for a 
Group 1 heavy duty power operated vehicle (K0801). Therefore, we decided that the Plan does not have to pre-
approve a Group 1 heavy duty power operated vehicle, patient weight capacity 301 to 450 pounds (K0801).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0272) provided on August 29, 2023.  
 
You asked the Plan to pay for the dental service. You say that you though the Plan was covering the x-ray and 
if they were not you would not have gotten the x-ray. 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 the Plan paid for the bitewings (D0274) on May 24, 2023; therefore, your benefit for the requested item 
or service was exhausted on the date of service of May 24, 2023. Therefore, we decided that the Plan does not 
have to pay for the bitewings (D0272) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing (D4341) provided on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-bed table provided from August 21, 2023, to 
September 20, 2023. 
 
You asked the Plan to pay for the over-bed table. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the over-bed table provided from August 21, 2023, to September 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown (D6752) provided on July 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 7, 2023. Therefore, 
we decided that the Plan does not have to pay for retainer crown (D6752) provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 28, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-ray (D0220) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral x-ray (D0220) provided on August 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 25, 2023. 
 
You asked the Plan to pay for the panel. You say that fadsfsa The Plan denied your request. The Plan says the 
panel should be billed with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2330, D2392) and crown 
(D2740) provided on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited budget and the Plan 
incorrectly informed you that your Plan is a preferred provider organization (PPO). Due to the Plans mistake 
these services should be covered. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the resin-based composites (D2330, D2392) and crown (D2740) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction of erupted tooth (D7140) and gingival irrigation 
(D4921) provided on May 2, 2023. 
 
You asked the Plan to pay for extraction of erupted tooth (D7140) and gingival irrigation (D4921). You say 
that you asked the provider if the service was covered. You also said the provider's office said yes, it was 
covered. The Plan denied your request. The Plan says this service is not a covered expense 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 extraction 
of erupted tooth (D7140) and gingival irrigation (D4921) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance an extraction of teeth #2 and #5, endosteal 
implant on teeth #5 and #12, and prefabricated abutment on teeth #5 and #12 (D6056, D7210, D6010) provided 
on April 13, 2023. 
 
You asked the Plan to waive the coinsurance the dental services. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. Additionally, your benefit for the requested services was exhausted. Moreover, 
this benefit does not include prefabricated abutments. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2023. 
 
You have been asked to pay a 50% coinsurance for endosteal implants and extractions. This item/service falls 
within the Dental services 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 coinsurance an extraction 
of teeth #2 and #5, endosteal implant on teeth #5 and #12, and prefabricated abutment on teeth #5 and #12 
(D6056, D7210, D6010) provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive complete series of 
radiographic images (D0210), and 2D oral/facial photographic image obtained intra-orally or extra-orally, 
(D0350) provided on August 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have a free checkup with or without 
insurance. You also say that there was no service performed for the x-rays, and your tooth fell off on its own. 
The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered expense 
under your dental plan. The Plan also says your benefit for the full mouth x-rays 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, the 2D oral/facial photographic image 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on August 7, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral x-rays complete series of radiographs images was exhausted on date of 
service August 7, 2023. You received a panoramic radiograph x-ray (D0330) on the appealed claim. Therefore, 
we decided that the Plan does not have to pay for the intraoral  comprehensive complete series of radiographic 
images (D0210) provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 24, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service March 28, 2023.  
  
 
Specifically, the Plans contract states that one comprehensive oral evaluation is covered every three years. 
You previously received this service on March 28, 2023, less than three years prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #29 provided on July 20, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that the dentist office got an estimate from the 
Plan and it said you would owe $0. The Plan denied your request. The Plan says your dental maximum benefit 
for the year has already been exhausted. Also, it was verified you did not contact the Plan prior to the date of 
service to verify benefits or how much was left of the annual maximum for the year. 
 
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 the Plan paid $338 for dental services on May 8, 2023. On July 20, 2023, the Plan paid $162 for dental 
services. For the year of 2023 the Plan paid $500 ($338 paid + $162 paid) for dental services; therefore, your 
dental maximum benefit for the year of 2023 was exhausted on the date of service of July 20, 2023. Therefore, 
we decided that the Plan does not have to pay more for a crown (D2740) for tooth #29 provided on July 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057), and abutment supported retainer for porcelain/ceramic FPD (D6068) for tooth 18. 
 
You asked the Plan to pre-approve the dental services. You say that currently your dental implant work is with 
the 4 screws, lower buccal which started in 2022. You also say that the work has not been able to be finished 
and you need this resolved as you need a better quality of life for your teeth. The Plan denied your request. The 
Plan says your benefit for the requested 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 service was exhausted on date of service January 13, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057), and abutment supported retainer for porcelain/ceramic FPD (D6068) for tooth 18.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor and receiver (E2103, A4239) provided on 
June 24, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor and receiver (E2103, A4239) provided on June 24, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and intraoral x-ray (D0140, D0220) 
provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation and intraoral x-ray (D0140, D0220) provided on July 12, 2023.