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

 
We decided that the Plan does not have to pay for the endodontic therapies, of a molar tooth (excluding final 
restoration) (D3330 x 2) and the dental crowns-porcelain fused to noble metal (D2752 x 4) provided on April 8, 
2023. 
 
You asked the Plan to pay for these dental items/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 dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the items/services provided 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 endodontic therapies, of a molar tooth (excluding final restoration) (D3330 x 2) and the dental 
crowns-porcelain fused to noble metal (D2752 x 4) provided on April 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused  (D0140) 
provided on May 30, 2023. We also decided that the Plan does not have to pay more for the intraoral - 
periapical first radiographic image (D0220), and resin-based composite - four or more surfaces or involving 
incisal angle (anterior) (D2335) provided on May 30, 2023. 
 You asked the Plan to pay for the limited oral evaluation - problem focused. You also asked the Plan to pay 
more for the intraoral - periapical first radiographic image and resin-based composite - four or more surfaces or 
involving incisal angle (anterior). You say that in your opinion the explanation of billing was too much for the 
services provided. The Plan denied your request. The Plan says your benefit for the limited oral evaluation - 
problem focused has already been exhausted. The Plan also says that 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. 
 
You have been 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 intraoral - periapical first radiographic image 
(D0220), and resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) 
provided on May 30, 2023 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused was exhausted on dates of service January 
19, 2023, and January 31, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation - problem focused  (D0140) provided on May 30, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210), comprehensive oral evaluation - new or established patient (D0150), and full mouth debridement to 
enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit (D4355) provided on April 
12, 2023 
 
You asked the Plan to pay for the dental services. You say that the billing staff indicated that the services 
would be fully covered. The Plan denied your request. The Plan says your benefit for the intraoral  
comprehensive series of radiographic images and comprehensive oral evaluation has already been exhausted. The Plan also says there is no coverage for dental code D4355 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 full mouth debridement is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for full 
mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 
(D4355) provided on April 12, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral  comprehensive series of radiographic images and comprehensive oral 
evaluation was exhausted on date of service April 20, 2022. Therefore, we decided that the Plan does not have 
to pay for the intraoral  comprehensive series of radiographic images (D0210), comprehensive oral evaluation 
- new or established patient (D0150) provided on April 12, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dental office informed you that they took 
your insurance and you understood that to be true. 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 - established patient 
(D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on April 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0562) provided on 
February 1, 2023. 
 
You asked the Plan to pay for procedure code E0562. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case for the date of 
service at issue. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
(E0562) provided on February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 76376 billed for date of service April 5, 
2023.  
 
You asked the Plan to pay for procedure code 76376. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76376 is 2. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76376 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76376 billed for date of service April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #7, #8, #9, and #10 and a 
retainer crown (D6751) for tooth #6 and #11. 
 
You asked the Plan to pre-approve the dental services. You say that the dentist recommended a bridge, and it 
was denied as not a covered benefit, but it is medically necessary for the enrollee to get a bridge. The Plan 
denied your request. The Plan says the denial of authorization for these services is correct, because bridges 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 pre-approve a 
pontic (D6241) for tooth #7, #8, #9, and #10 and a retainer crown (D6751) for tooth #6 and #11.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on April 12, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on  
April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips as you have 
many health problems that you need addressed. You also say that you only have 6 trips available. The Plan 
denied your request. The Plan says your request exceeds the benefit limit for the transportation program. 
 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 a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for your health problems. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on January 27, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
January 24, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid providers.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid providers. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97810, 98940) provided on June 2, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not emergent or pre-approved. 
 
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 chiropractic services (97810, 98940) provided on 
June 2, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) ad a core build-up (D2950) provided on 
June 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that 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 a crown (D2740) ad a core build-up (D2950) provided on June 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on February 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed codes. 
 
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, the CPT Code Manual definition of code G0483 is Drug Testing, definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 22 
or more drug classes were tested. There's a more appropriate code for this service (G0482). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (G0483) provided on February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs from March 14, 2023, through 
March 18, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 self-administered drugs from 
March 14, 2023, through March 18, 2023.  
 
Benefits for the medication 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 pre-approve crowns - porcelain/ceramic teeth #'s 2, 15, 18 and 19 
(D2740). 
 
You asked the Plan to pre-approve the crowns. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the additional information received did not include evidence of pathological 
destruction to the tooth that meets the criteria for approval.  
 
 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the provided documentation shows old and 
stained amalgam restorations with no obvious fractures seen. The provided radiographs show one surface 
restorations without any recurrent decay seen. In this instance there is sufficient remaining structure such that a 
replacement restoration with conventional materials would be most appropriate and would save as much 
natural tooth structure as possible. Core buildups are only necessary where a crown is found to be necessary, 
and there would be insufficient structure to retain the crown. 
 
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 the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns - porcelain/ceramic teeth #'s 2, 15, 18 and 19 (D2740).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 29, 2023, to 
May 4, 2023. 
 
You asked the Plan to pay for the medication. You say that you should be reimbursed for medications provided 
by the hospital. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 self-administered drugs provided 
from April 29, 2023, to May 4, 2023.  
 
Benefits for the medication 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 more for a complete maxillary denture (D5110) provided on 
November 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware how your out-of-
network benefits worked. 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. 
 
You have been 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 a complete maxillary denture (D5110) 
provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) provided on April 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that your dental plan covers $5,000 for dental 
services and could be used for this procedure. 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 bone 
replacement graft (D4263) provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7320 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that without this procedure you would be in 
extreme pain while using dentures. 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 pre-approve 
alveoloplasty (D7320 x 2).