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

 
We decided that the Plan does not have to pay for the core buildup (D2950) and the endodontic therapy 
(D3310) provided on October 20, 2022, and October 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told your dental maximum for the 
year was $4,000. The Plan denied your request. The Plan says your maximum dental benefit for the year has 
already been exhausted. Also, the Plan verified the enrollee was correctly advised of the maximum dental 
allowance 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 your maximum dental benefit for the year was exhausted on the date of service of October 21, 2022. On 
September 15, 2022, the Plan paid $115 for dental services. On October 20, 2022, the Plan paid $247 for dental 
services. On October 22, 2022, the Plan paid $1,638 for dental services. For the year of 2022 the Plan paid a 
total of $2,000 ($115 paid + $247 paid + $1,638 paid) for dental services. Therefore, we decided that the Plan 
does not have to pay for the core buildup (D2950) and the endodontic therapy (D3310) provided on October 
20, 2022, and October 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the labs and the ultrasound did not determine the 
cause of weight loss. The Plan denied your request. The Plan says the records do not show that results of a 
thorough workup failed to reveal the cause of the enrollee's weight loss. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan of the abdomen and pelvis is not medically necessary. Our physician reviewer found that the enrollee 
reports unexplained weight loss but notes from last encounter indicate they have gained 13 pounds since their 
last visit 1 year before. The enrollee was scheduled to have a screening colonoscopy on December 31, 2022, 
but no results are in the records. The enrollee had a normal abdominal ultrasound on December 13, 2022, but 
no pelvic ultrasound. The enrollee also has a prior history of gastritis and esophagitis with dilatation in 2008 
but no recent gastrointestinal (GI) evaluation of her upper GI tract. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the esophagogastroduodenoscopies 
(EGDs) (43239), diagnostic colonoscopy (45378), and anesthesia (00813) provided on August 24, 2022. 
 
You asked the Plan to waive the coinsurance for the EGDs, diagnostic colonoscopy, and anesthesia. You say 
that your colonoscopy should be covered at 100%, with no deductible. You also say that you had to pay 
$318.45 for this test, and you believe this amount should be reimbursed. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
 
 
 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 20% 
coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a 20% coinsurance for the EGDs, diagnostic colonoscopy, and anesthesia. These 
services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 for the 
esophagogastroduodenoscopies (EGDs) (43239), diagnostic colonoscopy (45378), and anesthesia (00813) 
provided on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete upper denture (D5110) and a partial lower 
denture (D5214) provided by an out-of-network provider on October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reimburse you 
for the dentures because they were needed. 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 upper denture (D5110) and a 
partial lower denture (D5214) provided by an out-of-network provider on October 20, 2022.
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 August 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
glucose level dropped after an exercise class and you fell. You also say the paramedics arrived minutes later 
and administered an IV. 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 August 29, 2022. 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 August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance procedures when prostheses are 
removed and reinserted, including cleansing of prostheses and abutments (D6080) provided on October 14, 
2022. 
 
You asked the Plan to pay for implant maintenance procedures (D6080). You say that your upper prosthesis is 
screwed into the implant. You also say that hygiene treatments cannot occur unless the device is removed. The 
Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 implant 
maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and 
abutments (D6080) provided on October 14, 2022.
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 October 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not request the ambulance and when they arrived, they checked your pulse and completed the paperwork. You 
also say that you didn't need the ambulance transport to the hospital and left with your daughter. 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 October 17, 2022. 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 October 17, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery services provided on March 9, 2022. 
 
You asked the Plan to pay for the outpatient surgery services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough information to render a decision. 
The case file contains a case narrative for the incorrect enrollee and the final determination letter provides no 
denial rationale. The Plan provided no Medicare regulations used in their decision for review. Therefore, we 
decided that the Plan has to pay for the outpatient surgery services provided on March 9, 2022.  
 
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 pontic (D6251) for tooth #28 provided on October 18, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you still have credit on your annual dental 
maximum and would like the Plan to pay for the dental service. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the pontic is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
(D6251) for tooth #28 provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral radiographic 
images (D0220), and a cleaning (D110) provided by an out-of-network provider on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have never received a dental bill before. 
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), intraoral radiographic images (D0220), and a cleaning (D110) 
provided by an out-of-network provider on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and extractions (D7210) on tooth 
#24 and #25 provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
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 oral evaluation was exhausted on the date of service of January 18, 2022. 
Documentation received shows the Plan paid for an oral evaluation on January 3, 2022, and January 18, 2022. 
The record shows your benefit for the extractions was exhausted on the date of service of February 10, 2022. 
Documentation received shows the Plan paid for extractions on January 5, 2022, and February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) and extractions 
(D7210) on tooth #24 and #25 provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, and molar (D0140, 
D0220, D3330) provided on August 31, 2022. 
 
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, intraoral x-ray, and molar (D0140, D0220, D3330) provided on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says this request does not 
show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient 
only status. The Plan also says that the services the enrollee requires can safely be received at a different 
setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation-problem focused (D0140), 
periapical x-rays (D0220, D0230), re-cement or re-bond crown (D2920), and oral hygiene instructions (D1330) 
provided from December 20, 2021, to April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration of payment 
for the dental services you received. The Plan denied your request. The Plan says these services are 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 a limited 
oral evaluation-problem focused (D0140), periapical x-rays (D0220, D0230), re-cement or re-bond crown 
(D2920), and oral hygiene instructions (D1330) provided from December 20, 2021, to April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration (D4266). You say that you have an infection 
which could eventually spread throughout your entire body. You say you need this service. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the guided tissue regeneration (D4266) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve the guided tissue regeneration (D4266).
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 July 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
appealing the service because it is too much money and you are on social security. You also say that you did 
not go to the hospital and will pay the $45 for the ambulance treatment. 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 July 8, 2022. 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 July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2022. 
 
You asked the Plan to pay for lab services. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services provided on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 4, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with coinsurance. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $275.70. 
You are being asked to pay $55.14 ($275.70 x 20% = $55.14). 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 
for durable medical equipment (DME) provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on October 18, 2022.