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

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided January 12, 2022. 
 
You asked the Plan to pay for the complete upper and lower dentures. You say that your dentures were 
approved in December 2021, and you were unaware that your insurance would change in 2022. You have since 
changed your dental insurance and would like the dentures to be covered. The Plan denied your request. The 
Plan says dentures are not covered under your 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 denture - maxillary (D5110) and complete denture - mandibular (D5120) provided January 12, 2022.  
 
Your complaint about your change in benefits in 2022 is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 22, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you are living on a fixed income and cannot afford 
to have to pay for services that your dental insurance should have paid for. The Plan denied your request. The 
Plan says your $1,500 benefit maximum was met prior to the processing of this claim. 
 
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 Plan offers a $1,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on October 13, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Excision of lesion or tumor (41825) 
provided on November 5, 2021. 
 
You asked the Plan to waive the copayment for the Excision of lesion or tumor. You say that you feel you 
should not be responsible for this cost share amount because you did not receive these services. The Plan 
denied your request. The Plan says you received services obtained by a specialist on the date of service at issue 
in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. The Plan 
says that a fraud tip was submitted on your behalf. 
 
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 
copayment for services obtained from a specialist.  
 You have been asked to pay a $20 copayment for the Excision of lesion or tumor. The Excision of lesion or 
tumor falls within the Physician/Practitioner services 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 the Excision of lesion or tumor (41825) provided on November 5, 2021.  
 
Your complaint about not receiving these services is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on September 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you found the provider on the plan's website to 
be in-network. The Plan denied your request. The Plan says that the services are not covered as the dental 
provider is out-of-network. 
 
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 says the dental provider is not a participating provider with the Plan. 
The enrollee says they went to the Medicare website for the Plan where they found the provider. 
Under the supplemental dental benefit section of the contract, the directions to see participating providers is to 
either call member services or visit the website. Upon visiting this website, we were able to click on find a doctor which includes a link for dental under specialty care. Once you click on dental, we were able to enter the enrollee's zip code to find participating dentists and the first dental office to load was a provider, where the provider at issue is affiliated with. This 
means that the enrollee would have easily believed the provider to be contracted with the Plan. Therefore, we 
decided that the Plan has to pay for the dental services provided on September 2, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller (CPT code E2313), and control interface module (CPT code K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the DME have not been met. Upgraded electronics cannot be covered per Medicare rules. They are 
necessary when there is a medical need to control power options though the joystick. The notes do not show a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. These switches can be made any size without asking for a separate request. They can be made 
from any material without asking for a separate request. All of this can be done without the need to use the 
joystick to control the power features. The requested joystick module controller display is included with the 
requested controller. Therefore, we decided that the Plan does not have to pre-approve expandable controller, 
including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), 
harness for upgrade to expandable controller (CPT code E2313), and control interface module (CPT code 
K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81292, and 81301) provided 
on September 14, 2021. 
 
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 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81292, and 81301) provided on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core, in addition to crown (D2954) 
amalgam-one surface, primary or permanent (D2140) provided November 9, 2021 to December 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are being billed by the provider for the 
dental services received. The Plan denied your request. The Plan says these services exceed the annual 
maximum benefit. 
 
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 after the $3,000 annual 
maximum is exhausted, any remaining charges are your responsibility. 
 
You have been asked to pay $282.00 for the dental services. The Plan has a $3,000 annual maximum. After the annual maximum is exhausted, any remaining charges are your responsibility.  The services fall within the 
Dental services 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 pay for prefabricated post and core, in addition to 
crown (D2954) amalgam-one surface, primary or permanent (D2140) provided November 9, 2021 to December 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cardiovascular screening panel (81404, 81479) 
provided on June 3, 2021. 
 
You asked the Plan to pay for a hereditary cardiovascular screening panel. You say that this was medically 
necessary. The Plan denied your request. The Plan says there is no evidence to support the referring provider 
was treating the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular 
screening panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary 
cardiovascular screening panel (81404, 81479) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation and oral drugs you received on 
January 31, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not covered. 
 
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. The Plan covers only those dental services for which the codes are listed in 
the Evidence of Coverage. Dental codes D9630 and D4921 are not listed, and therefore are not covered. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation and oral drugs you received 
on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem-focused limited oral evaluation and bone 
replacement graft rendered from December 1, 2021 to December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 problem-focused limited oral evaluation and bone replacement graft rendered from December 1, 2021 to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction (D7210) provided on February 16, 2022. 
 
You asked the Plan to pay for dental code D7210. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D7210 is not covered under the 
Plan's supplemental dental 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, dental code D7210 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental extraction 
(D7210) provided on February 16, 2022.  
 Your complaint about not receiving your benefit card is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received on January 4, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network 
service are not covered in full. 
 
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 require a higher 
cost share when provided by an out-of-network provider. The Plan only pays up to the maximum allowable 
amount for out-of-network dental services. You are responsible for any amount billed by the provider in excess of the maximum allowable. Therefore, we decided that the Plan does not have to pay for the dental services you 
received on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services (D2740 and D2950) provided 
on January 19, 2022. 
 
You asked the Plan to pay additionally for dental codes D2740 and D2950. You say that you would like the 
Plan to reconsider your request. The Plan denied your request. The Plan says per your plan dental benefits, 
covered dental services may not exceed $1000 every year. Per your claim history, you reached the benefits 
maximum of $1000 while processing the claim for dental services you received on January 19, 2022. 
 
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. 
 
 We looked at the file and the Plan's rules. Per your plan dental benefits, covered dental services may not exceed 
$1000 every year. Per your claim history, you reached the benefits maximum of $1000 while processing the 
claim for dental services you received on January 19, 2022. The file shows you reached your $1000 maximum 
between the January 3, 2022, date of service and the January 19, 2022 date of service. Therefore, we decided 
that the Plan does not have to pay additionally for the dental services (D2740 and D2950) provided on January 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam you had on January 7, 2022. 
 
You asked the Plan to pay for the exam. You say that the services had nothing to do with dental work. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral exam you had on 
January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture, maxillary (D5130) provided on 
March 30, 2021. 
 
You asked the Plan to pay for the immediate denture, maxillary. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says you are covered for removable dentures 
(complete, immediate or partials) once in any 5-year period. You received a partial denture on May 28, 2019, 
which is less than 5 years ago. 
 
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. 
 We looked at the file and the Plan's contract. The contract clearly says you are covered for removable dentures 
(complete, immediate or partials) once in any 5-year period. The file shows that you received a partial denture 
on May 28, 2019, which is less than 5 years ago. Therefore, we decided that the Plan does not have to pay for 
the immediate denture, maxillary (D5130) provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 29, 2021, billed with code 
87150. 
 You asked the Plan to pay for the lab testing. You say that this testing is medically necessary. The Plan denied 
your request. The Plan says the claim was billed with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab testing provided on May 29, 2021, billed with code 87150.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implants provided on April 20, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says they paid for tooth #20 and tooth #19 is denied 
because you exhausted your benefit frequency limit. 
 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. 
 
Review of the file shows that you had two (2) implants placed on April 20, 2021. The one at tooth #20 was 
paid. The one on tooth #19 was denied. Your 2021 EOC states, one implant is covered every five years. 
Additionally, the one that was paid is covered at 50% coinsurance of the covered plan allowance. Furthermore, 
this provider is not a participating provider. Therefore, we decided that the Plan does not have to pay for the 
dental implants provided on April 20, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment services (CPT code(s): D6057 
and D6058) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit 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. The services are not listed in your 2022 EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for custom 
fabricated abutment services (CPT code(s): D6057 and D6058) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), bitewings - four radiographic images (D0274) and panoramic radiographic image 
(D0330) provided February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral exam, periapical x-rays, bitewing x-rays and panoramic 
x-ray. You say that you did not know you needed to use an in-network provider. The Plan denied your request. 
The Plan says these services are not covered because they were provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral exam, periapical x-rays, bitewing x-rays and panoramic x-ray when the services are 
rendered by a provider in the Plans Dental network.   
We looked at the file and Medicare rules. The service in this case were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the comprehensive oral exam, periapical x-rays, 
bitewing x-rays and panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - 
four radiographic images (D0274) and panoramic radiographic image (D0330) provided February 9, 2022, by 
an out-of-network (OON) provider.