Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatments (98941 x 4) provided from 
September 23, 2022, through October 13, 2022. 
 
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 that these services are not payable as you have 
exhausted the allowable routine chiropractic benefit. 
 
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. The Plan has issued their denial stating that you have exhausted the allowable 
routine chiropractic benefit. However, the Plan has not provided substantive evidence that indicates thirty visits 
for routine chiropractic care had been provided or paid for by the Plan. The Plan has not substantiated their 
denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the chiropractic 
manipulative treatments (98941 x 4) provided from September 23, 2022, through October 13, 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 dental assessment services (D0191) provided on October 6, 
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 dental 
assessment services (D0191) provided on October 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care. 
 
You asked the Plan to pay for custodial care. You say that you need help at home. The Plan denied your 
request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for COVID-19 test kits purchased on July 6, 2022. 
 
You asked the Plan to pay more for COVID-19 test kits. You say that you went to purchase COVID-19 test kits 
and were informed the pharmacy did not have any in stock so you were instructed to purchase them out-of-
network and file for reimbursement afterward. You also say you have only received $36 of the $99 spent. The 
Plan denied your request. The Plan says denied the enrollees request for an additional reimbursement of $42 
because this amount is above $12 per test which exceeds the allowance in accordance with the Federal 
mandate. 
 
The Plan must follow Medicare rules Medicare rules say that enrollees cannot submit a claim for these tests to 
Medicare or their MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative. We looked at the file and Medicare rules. The rules say that enrollees cannot submit a claim for these tests to 
Medicare or their MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative. 
Based on this information, we decided that Medicare rules for coverage of COVID-19 test kits have not been 
met. Therefore, we decided that the Plan does not have to pay more for COVID-19 test kits purchased on July 
6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination and retinal imaging provided on 
August 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a routine eye examination and retinal imaging. You say that you want to be 
reimbursed for your eye examination and retinal imaging. The Plan denied your request. The Plan says they 
cover an annual eye examination when received from a participating network provider. The Plan also says that 
retinal imaging is not a covered benefit. 
 
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. 
 
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 an annual eye examination when received by an in-network provider. Retinal 
imaging is excluded from this benefit 
 
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. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover annual eye examinations when 
received by an in-network provider. The record shows you went to an out-of-network provider for this service. 
The record also shows that retinal imaging is excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of a routine eye examination and retinal imaging have not been met. 
Therefore, we decided that the Plan does not have to pay for a routine eye examination and retinal imaging 
provided on August 18, 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 additional intraoral x-rays (D0230) provided on December 
23, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 23, 2021. 
Therefore, we decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on 
December 23, 2021.
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 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
unsure of the reason for this claim to be denied as it was a legitimate medical emergency. You also say that you 
were already going to the medical facility for a regular appointment so the paramedics assisted you into your 
vehicle. 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 13, 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 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health therapies provided on August 31, 
2022, to September 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health therapies. You say that the Plan should submit the 
payments for the claims as they have paid for them before. The Plan denied your request. The Plan says there is 
no referral or authorization on file for the services provided. 
 
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 outpatient mental health therapies provided on 
August 31, 2022, to September 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 a resin-based composite - two surfaces, anterior (D2331) 
provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you tried to reach an in-network dentist but 
were not successful. You also say you opted to see the out-of-network dentist as you had a dental emergency. 
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 resin-based composite - two surfaces, anterior (D2331) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction; non-surgical 
access (D3331) and pulpal debridement, of primary and permanent teeth (D3221). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
treatment of a root canal obstruction; non-surgical access (D3331) and pulpal debridement, of primary and 
permanent teeth (D3221).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve monitoring testing provided on August 22, 2022. 
 
You asked the Plan to pay for nerve monitoring testing. You say that the primary surgeon requested  nerve 
monitoring during this surgery. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nerve monitoring testing 
provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dental health is at risk. 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 November 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110 and D5120).
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 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 February 15, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
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 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 dental 
services on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the reports attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 August 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a dental examination (D0120) and an adult cleaning (D1110) provided 
on September 22, 2022. 
 
You asked the Plan to pay for a dental examination (D0120) and an adult cleaning (D1110). You say that you 
were unaware that you used up your allowed amount for the year. The Plan denied your request. The Plan says 
that the benefits have been exhausted. 
 
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. The Plan states that the benefit has been exhausted. However, there is no 
evidence or verification of the date the benefit was exhausted, or that any other services other than the dental 
examination (D0120) and the adult cleaning (D1110) was completed this year. Without the verification, we 
cannot determine that the enrollee exhausted the dental benefits according to the EOC. Therefore, we decided 
that the Plan has to pay for a dental examination (D0120) and an adult cleaning (D1110) provided on 
September 22, 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 pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 upper partial denture was exhausted on December 19, 2018. Additionally, 
the record shows that your benefit for the requested lower partial denture was exhausted on February 5, 2019.  
Specifically, the Plan provides coverage for one upper partial denture and one lower partial denture every five 
plan years. You previously received an upper partial denture on December 19, 2018 and a lower partial denture 
on February 5, 2019, which were paid for by the Plan.  Therefore, you have exhausted the allowable benefit for these items. Therefore, we decided that the Plan does 
not have to pre-approve an upper partial denture (D5213) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on April 21, 
2022. 
 
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 the hearing aids purchased in this 
case are not covered. 
 
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 only 
for the type of hearing aids indicated in the Plans contract.  
 
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 hearing aids purchased in this case are not 
indicated on the list of covered items. Additionally, you signed a purchase agreement acknowledging that these 
hearing aids are not covered by the Plan. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in the presence of generalized moderate or severe 
gingival inflammation (D4346) provided on October 3, 2022. 
 
You asked the Plan to pay for dental services. You say that this provider is where the insurance company sent 
you. The Plan denied your request. The Plan says this service is not covered under 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 pay for scaling in 
the presence of generalized moderate or severe gingival inflammation (D4346) provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for foot orthotics. You say that you needed this orthotics. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
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 foot orthotics provided on May 19, 2022, by an 
out-of-network (OON) provider.