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

We decided that the Plan does not have to pay for the incisional biopsy (D7286) provided on July 8, 2020. 
 
You asked the Plan to pay for the incisional biopsy (D7286). You say that you needed dental care to eat and 
digest food properly. You say that you are appealing the denial of payment. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incisional biopsy (D7286) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and resin-based composites provided on 
June 5, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and resin-based composites. You say that you were informed 
if you had Medicare you were covered. You say that you weren't informed the services would not be covered. 
The Plan denied your request. The Plan says you must use a network dentist to obtain these supplemental 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-ray and resin-based composites provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on June 3, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 19, 2020. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
shows a urine sample was collected. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crowns provided on July 24, 2020. 
 
You asked the Plan to pay for the implant supported crowns. You say that you thought the implants were 
covered when you scheduled the restoration. You say that 50% of the cost should be covered. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant supported crowns provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided a participating 
provider on July 1, 2020. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you were told that this would be 
free. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for vision care (Medicare-covered)/in-network.  
 
You have been asked to pay a $35 copayment for an eye exam. The correct copayment has been applied to the 
vision services that were provided. An eye exam falls within the vision care (Medicare-covered)/in-network 
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 copayment for an eye exam provided by a 
participating provider on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture provided on July 1, 2020. 
 
You asked the Plan to pay for the lower partial denture. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the lower 
partial denture provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that you are requesting acupuncture for your chronic 
pain caused by Parkinson's disease. The Plan denied your request. The Plan says this service is not covered by 
Medicare or the Plan for your condition. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the medical record fails to indicate you have a history 
of low back pain. All types of acupuncture including dry needling for any condition other than chronic low 
back pain is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on July 8, 2020. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says this was not billed with a modifier to support this was a separate 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
has a Column One/Column Two relationship with code 71046, which was billed on a previous claim for this 
date of service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for an x-ray (71045) provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750, 90471) provided July 21, 2020. 
 
You asked the Plan to pay for the shingles vaccine. You say that the vaccine should be covered. The Plan 
denied your request. The Plan says this vaccine is not covered under the Part B Medical Benefit. Benefits may 
be available under the Part D Prescription Drug benefit. The enrollee must request reimbursement from the 
Plan's Part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750, 90471) 
provided July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays provided on June 15, 2020. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you went to this office because yours wasn't 
open. You say that you were informed the x-rays were free. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-rays provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the oral exam, prophylaxis, and x-rays 
provided on May 18, 2020. 
 
You asked the Plan to reimburse the full amount for the dental services. You say that the amount that you have 
been reimbursed so far is insufficient. You say that you are still due $84.25 for the services that you received. 
The Plan denied your request. The Plan says you paid a total of $240.75 for the services that you received on 
the date of services. The Plan also says that no further payment is due as 100% of the out of pocket costs have 
already been reimbursed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the out of pocket expenses for this date 
of service have already been reimbursed 100%. The Plan can only reimburse you for the amounts that you 
actually paid to the dental provider after any primary dental insurance payments and discounts. Therefore, we 
decided that the Plan does not have to reimburse the full amount for the oral exam, prophylaxis, and x-rays 
provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on June 23, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you never stayed 
overnight. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per day for days 1-7. There is a $0 copayment for additional services for inpatient hospital care/in-
network.  
 
You have been asked to pay a $225 copayment per day for days 1-7. There is a $0 copayment for additional 
services for an inpatient hospital stay. The total amount you are being asked to pay is $225. Evidence was 
provided that shows an admission and discharged happened on the same day; therefore, the correct copayment 
has been applied. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 copayment for an inpatient hospital stay provided by a participating 
provider on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial 15 minutes of deep sedation (D9222) 
and the additional 15 minutes of deep sedation (D9223) provided on July 30, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were advised that sedation is 
normally covered for 3 extractions but would be covered if medically needed. You say that the sedation was 
medically needed. You also say that you paid $250 for the sedation and should be reimbursed. The Plan denied 
your request. The Plan says deep sedation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of deep sedation (D9223) 
provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 genetic testing provided on April 11, 2020. 
 
You asked the Plan to pay for the Guardant360 genetic testing. 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. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 genetic testing provided on April 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an impacted, completely bony, tooth 
(D7240) and the removal of an impacted, partially bony, tooth (D7230). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services to be approved. 
The Plan denied your request. The Plan says the removal of an impacted, completely bony and partially bony, 
teeth are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of an 
impacted, completely bony, tooth (D7240) and the removal of an impacted, partially bony, tooth (D7230).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated by the medics in place. 
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 May 23, 2020. 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 services provided on May 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, fluoride application and 
periodontal maintenance provided on July 17, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, fluoride application and periodontal maintenance. 
You say that you are still covered under your regular policy for cleanings. You say that these services should 
be covered despite the exhaustions of your rider benefits. The Plan denied your request. The Plan says your 
annual maximum is exhausted.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward your dental benefits provided on February 27, 2020 and March 9, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation, fluoride application and periodontal maintenance provided on July 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for self-care/home management training services provided on 
June 8, 2020. 
 
You asked the Plan to pay for the self-care/home management training services. The Plan denied your request. 
The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for self-care/home management training services provided on June 
8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining amount for the oral exam, prophylaxis, bitewing 
x-rays, and panoramic x-ray provided on June 8, 2020 by the out of network dental provider. 
 
You asked the Plan to pay the remaining amount for the dental services. You say that you expected the services 
to be covered in full. You say that coverage is the same for in network and out of network services. You say 
that there is no reference to an approved amount limitation for an out of network provider. The Plan denied 
your request. The Plan says since the provider is out of network, the services are paid according to a maximum 
allowable fee schedule and you are responsible for all fees in excess of this amount from the billed amount. 
The Plan says the difference of billed amount and allowed amount is your responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you may be billed more when you 
receive dental services out of network. The difference of billed amount and allowed amount is your 
responsibility. Therefore, we decided that the Plan does not have to pay the remaining amount for the oral 
exam, prophylaxis, bitewing x-rays, and panoramic x-ray provided on June 8, 2020 by the out of network 
dental provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and lower partial 
denture (D5214) provided on June 2, 2020. 
 
You asked the Plan to pay for the complete upper denture (D5110) and lower partial denture (D5214). You say 
that the dentist informed you there was no other alternative but to have your teeth removed. You say that the 
dental package should cover the expense. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete upper denture (D5110) and lower partial denture (D5214) provided on June 2, 2020.