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

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), an 
intraoral - periapical each additional radiographic image (D0230), a periodic oral evaluation (D0120), 
bitewings (D0274) and an adult prophylaxis (D1110) provided on May 10, 2023. 
 
  You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), an intraoral - 
periapical each additional radiographic image (D0230), a periodic oral evaluation (D0120), bitewings (D0274) 
and an adult prophylaxis (D1110). You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says an intraoral - periapical first radiographic image (D0220), an intraoral - periapical 
each additional radiographic image (D0230) is not a covered benefit. The Plan also says that for a periodic oral 
evaluation (D0120), bitewings (D0274) and an adult prophylaxis (D1110), you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network provide. 
 
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, intraoral - periapical first radiographic 
images (D0220), an intraoral - periapical each additional radiographic images (D0230) are not among those 
covered under this benefit. You have also been asked to pay the difference between the out-of-network 
providers charges and the Plans payment for a periodic oral evaluation (D0120), bitewings (D0274) and an 
adult prophylaxis (D1110). 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 for an intraoral - periapical first radiographic 
image (D0220), an intraoral - periapical each additional radiographic image (D0230), a periodic oral evaluation 
(D0120), bitewings (D0274) and an adult prophylaxis (D1110) provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364) provided 
on February 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 January 16, 2019. 
Therefore, we decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364) provided on February 27, 2023. 
 
You asked the Plan to pay for the dental service. You are asking to please look at the history of this issue. You 
also say that you are paying the bill to the doctor and if you decide in your favor, please send reimbursement to 
you. The Plan denied your request. The Plan says your benefit for the cone beam CT capture 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 16, 2019.  Therefore, we decided that the Plan does not have to pay for a cone beam CT capture and interpretation with 
limited field of view  less than one whole jaw (D0364) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacing of broken teeth (D5640) provided on April 12, 
2023. 
 
You asked the Plan to pay for the replacing of broken teeth (D5640). You say that you called the Plan phone 
number and was given a provider name. You also say that the provider informed you that their office was not in 
your Plan. The Plan denied your request. The Plan says there is no coverage for broken teeth or dentures. 
 
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 
replacing of broken teeth (D5640) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite (D2393) provided on March 5, 2023. 
 
You asked the Plan to pay for resin-based composite (D2393). You say that the tooth cracked and was stuck in 
the gum. You also say that the cavity fell out and needed to be filled again. The Plan denied your request. The 
Plan says you did not enroll in the optional supplemental benefits for 2023. The Plan also says that you only 
have preventive and diagnostic dental benefits available. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite (D2393) provided on March 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that these charges should be covered. The Plan 
denied your request. The Plan says your annual dental maximum allowance amount has been 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. 
 
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 January 9, 2023. 
Therefore, we decided that the Plan does not have to pay for dental services provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) for 2 
quadrants provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you scheduled the appointments the year prior 
based off your coverage in 2022. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 1, 2023. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) 
for 2 quadrants provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a surgical removal of 
residual tooth roots (D7250) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this dentist was not 
participating in the health plan. You also say that you cannot afford to pay the bill. 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 limited oral evaluation (D0140) and a surgical removal of residual tooth roots (D7250) provided on 
May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for miscellaneous vision service (V2799), ultraviolet (U-
V) lenses (V2755), anti-reflective coating (V2750), tinting (V2745) and progressive lenses (V2781) provided 
on January 31, 2023. 
 
You asked the Plan to reimburse for miscellaneous vision service (V2799), ultraviolet (U-V) lenses (V2755), 
anti-reflective coating (V2750), tinting (V2745) and progressive lenses (V2781). You say that you tried using a 
flex card and at the time it was declined three times. You also say that you are requesting reimbursement. The 
Plan denied your request. The Plan says the items were purchased out-of-pocket with personal payment and not 
with the flex card. The Plan also says that per your EOC, other forms of payment used are not eligible for 
reimbursement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use the flex card. 
 
We looked at the file and the Plan's rules. The Plan rules say that the flexible benefit card (flex card) is a debit 
card that may be used to help reduce your out-of-pocket expenses for non-Medicare covered services in the 
vision category. The Plan contract says that the flex card must be used for payment. Any other forms of 
payment used are not eligible for reimbursement. Based on this information, we decided that the Plan's rules for 
coverage of miscellaneous vision service (V2799), ultraviolet (U-V) lenses (V2755), anti-reflective coating 
(V2750), tinting (V2745) and progressive lenses (V2781) have not been met. Therefore, we decided that the 
Plan does not have to reimburse for miscellaneous vision service (V2799), ultraviolet (U-V) lenses (V2755), 
anti-reflective coating (V2750), tinting (V2745) and progressive lenses (V2781) provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5212), replacing a tooth on a 
denture (D5520) for tooth #12 and #13, and the rebase of a complete upper denture (D5710) provided by an 
out-of-network provider on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the dental services had 
to be in-network. 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 partial lower denture (D5212), replacing a tooth on a denture (D5520) for tooth #12 and #13, and 
the rebase of a complete upper denture (D5710) provided by an out-of-network provider on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you would like to have the claim reprocessed in-
network. The Plan denied your request. The Plan says they did not find a valid referral on file for the service in 
question. 
 
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 an office visit provided on May 13, 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 palliative treatment of dental pain  per visit (D9110) 
provided on April 19, 2022. 
 
You asked the Plan to pay for palliative treatment of dental pain. You say that you thought this was covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for palliative 
treatment of dental pain  per visit (D9110) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and 
endodontic therapy, anterior tooth (D3310) provided on June 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you contacted all the Plan providers and 
no one accepts your plan, except one who did not answer the phone. 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 comprehensive oral evaluation (D0150) 
and endodontic therapy, anterior tooth (D3310) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64450 and 64447 billed for date of service 
May 9, 2023. 
 
You asked the Plan to pay for procedure codes 64450 and 64447. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 64450 and 64447 is bundled into 
payment for code 01402. 
 
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 codes 
64450 and 64447 are column II codes to column I code 01402. 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 codes 64450 and 64447 billed for 
date of service May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retreatment of previous root canal therapy - molar (D3348), 
and cone beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) 
provided on June 1, 2023. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy and cone beam CT capture and 
interpretation. You say that tooth #19 had been treated by the dentist and was incomplete, became infected and 
needed to be retreated.  You also say that the Plan should help with the cost since the initial procedure was faulty.  The Plan denied 
your request. The Plan says your benefit for the requested services $2,100 dollar limit was 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on dates of service March 30, 2023, and April 4, 
2023. Therefore, we decided that the Plan does not have to pay for a retreatment of previous root canal therapy 
- molar (D3348), and cone beam CT capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) provided on June 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 21, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you lost 
consciousness and an ambulance was called. You also say that once they had arrived you had regained 
consciousness and decided not to go to the hospital. The Plan denied your request. The Plan says these services 
are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 22, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation substantiates the services 
rendered. The Plan denied your request. The Plan says the billed code is not supported. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee was 
symptom free at the time of presentation, denying abdominal pain, chest pain, shortness of breath, vision 
changes, and syncope. The records do not show that a high level of medical decision making was provided. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of 
service March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87798 billed for date of service 
March 21, 2023. 
 
You asked the Plan to pay for procedure codes 87640 and 87798. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. The records provided do not support the billing of modifier 59 to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We also find that CPT code 87798 is not supported in the medical record. Specifically, this code is a not 
otherwise specified code, and the documentation does not contain a complete description of the not otherwise 
specified code. Based on this information, we decided that Medicare rules for coverage of procedure code 
87798 has not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87640 
and 87798 billed for date of service March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation-per site 
(D7953 x 2) and the unspecified removable prosthodontic procedure, by report (D5899) provided on May 22, 
2023. 
 
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 these services are not covered under the 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation-
per site (D7953 x 2) and the unspecified removable prosthodontic procedure, by report (D5899) provided on 
May 22, 2023.