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

 
We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 6 provided on January 
8, 2022. 
 
You asked the Plan to pay for the core build up. You say that you do not understand why your plan is willing to 
cover individual crowns but not a bridge. You say that you are not a candidate for a denture or implants. You 
also say that you cannot afford this dental work without your dental coverage helping to pay for this care. The 
Plan denied your request. The Plan says the service denied correctly. 
 
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 core build up for tooth # 6 is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
build up (D2950) for tooth # 6 provided on January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
one pontic (D6245), two retainer crowns (D6740 x2) provided on January 21, 2021. 
 
You asked the Plan to pay for the core buildup, one pontic, and retainer crowns. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says these services are not covered expenses 
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 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. Crowns are limited to one procedure code per calendar year. The 
record shows that the Plan made an exception and covered one pontic (D6245) provided on January 21, 2021 at 
the in-network rate, due to the Evidence of Coverage not specifying exactly which types of crowns are covered, 
and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
core buildup, including any pins when required (D2950), one pontic (D6245), two retainer crowns (D6740 x2) 
provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4341) 
provided on April 29, 2021, and May 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the scalings and planings. You say that you would like this claim to be paid 
because these services were approved by the Plan. You also say that the letter did not indicate that the treating 
provider was OON. The Plan denied your request. The Plan says the OON liability was applied correctly per 
your plan 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, you are responsible for a 50% 
coinsurance for each periodontal scaling and root planing (D4341), plus the difference between the billed 
amount and allowed amount because these services were received OON. Therefore, we decided that the Plan 
does not have to pay more for the periodontal scalings and root planings (D4341) provided on April 29, 2021, 
and May 13, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from September 13, 2021, to 
October 26, 2021, by out of network providers. 
 
You asked the Plan to pay for the dental services. You say that you fell on your face which resulted in the 
necessary dental work. You say that your dentist told you that effective September 1, 2021, they would no 
longer be in network. You say that you were not in a hurry to find a new provider. You say that you contacted 
your plan for a list of in network dentist. You also say that this accident happened on September 10, 2021. The 
Plan denied your request. The Plan says the providers in this case are out of network. The Plan says that 
services received out of network 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, dental services that you receive out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services provided from September 13, 2021, to October 26, 2021, by out of network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like to be 
reimbursed for these services. The Plan denied your request. The Plan says these services were rendered by an 
OON, Medicare opt out provider. 
 
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 are responsible for a $30 copay for 
preventive dental services that are received OON. The Evidence of Coverage does not state that dental services 
rendered by a Medicare opt out provider are not covered. The documentation also does not show that you 
signed a private contract with the treating provider acknowledging that you would be responsible for the full 
charges for these services because the treating provider had opted out of Medicare. Therefore, we decided that 
the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on 
December 6, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the core buildup, including any pins when required (D2950) provided 
on January 4, 2022. 
 
You asked the Plan to pay for the core buildup. You say that prior to this service being rendered, you were told 
that there would be no out of pocket expense for you because it was a covered procedure. You also say that if 
you had known this service would not be covered, you would not have had the procedure rendered. The Plan 
denied your request. The Plan says that this service is not a covered expense under your dental plan. The Plan 
also says that when you contacted the Plan on January 3, 2022, you were advised that the crown is a covered 
benefit, and no inaccurate information was given. 
 
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 did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the core buildup, including any pins when required (D2950) provided on January 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on July 13, 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 separately payable. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. The -59 modifier is 
not supported as a separate and distinct procedural service. Therefore, we decided that the Plan does not have 
to pay for the mass spectrometry rendered on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing 
x-rays (D0274) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that the enrollee's first appointment of the year was 
covered. You say that this appointment should be covered too. You say that it is not your responsibility to write off the difference when you were counting on the rest of the allowed $300. You also say that this is in the best 
interest of the enrollee. The Plan denied your request. The Plan says the claim denied correctly. 
 
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, dental services performed by an out of 
network provider are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on 
November 4, 2021.
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. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 daily skilled services are not necessary. Our physician reviewer found records do not document the need for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking household distances with a rolling walker with close supervision and is close supervision for transfers. Provided records do not document a significant decline in the enrollee's functional status to necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this case.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 19, 
2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have never paid a 
copayment for lab work before. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $10 
copayment for laboratory tests.  
 
The record shows the lab work, and the office visit did not happen on the same day. Therefore, a cost sharing 
amount applies. You have been asked to pay a $10 copayment for laboratory services. Laboratory services falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 5, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that the treating provider is in-network. You also say 
that you know the provider is participating because you went to this provider in the beginning of the year for a 
cleaning. The Plan denied your request. The Plan says dental services are only covered when performed by a 
participating general dentist. The Plan also says that there is no benefit for dental services performed by an 
OON 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on November 5, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 21, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that this service was provided for a dental 
emergency. You also say that the x-ray was essential for abscess of tooth and gum. The Plan denied your 
request. The Plan says the frequency limit for this service has been exceeded. 
 
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, bitewing x-rays are limited to one 
procedure per plan year. The record shows that you received bitewing x-rays (D0274) on August 31, 2021 and 
your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the bitewing x-rays (D0274) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the filling (D2331), scaling and root 
planing (D4342), localized delivery of antimicrobial agents (D4381 x 2), and take home drugs (D9630) 
provided on November 24, 2021. 
 
You asked the Plan to pay the in network rate for the dental services. You say that your provider directory and 
the website advise that the facility is a participating dental group. You say that you received a bill for $263.20. 
You say that when you spoke to your dental plan you were advised the provider was not participating. You also 
say that you would like this to be paid as in network. The Plan denied your request. The Plan says the provider in this 
case is out of network. The Plan also says that out of network dentists may bill you more than what the 
plan pays the provider. 
 
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 and filling and scaling and root planing 
are listed as covered, there are coinsurance amounts that apply. These are a contractual obligation you agreed to 
when you enrolled in the Plan's dental coverage. The coinsurance amounts are applied to the in network fee 
schedule amount. Out of network providers may bill you for any remaining amount. Localized delivery of 
antimicrobial agents and take home drug are not among those covered under this benefit. Additionally, the 
provider directory clearly states that the provider in this case is not effective with the Plan until 2022. 
Therefore, we decided that the Plan does not have to pay the in network rate for the filling (D2331), scaling and 
root planing (D4342), localized delivery of antimicrobial agents (D4381 x 2), and take home drugs (D9630) 
provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection (E2311). You say that the requested electronic 
connection (E2311) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic connection (E2311). 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 an electronic connection (E2311). Our 
reviewer says that the enrollee does not meet criteria for the requested electronic connection (E2311). Our 
physician reviewer found an expandable controller is an electronic system that is capable of accommodating 
one or more additional features and can operate 3 or more powered seating options.  
 
In this case, the member meets criteria for use of a power mobility device. The requested accessory is not 
medically necessary as he does have use of his hands and can operate and control the power options using the 
switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection (E2311) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
January 5, 2022, to January 25, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that these were all follow-
up appointments for the same surgery so you should not have copayments. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for each in-person specialist visit.  
 
You have been asked to pay a $40 copayment for each of the 4 specialist office visits, for a total of $160. 
Please note that the Plan has indicated follow-up visits have no copayment only within 10 days of the surgery. The specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 
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 copayments for specialist office visits provided 
from January 5, 2022, to January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on October 
11, 2021. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that your PCP advised you to go 
to urgent care. You say that you should only pay the $10 PCP copayment for this reason. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for each urgent care visit from a provider other than your PCP.  
 
You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 reduce the copayment for an urgent care visit provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vascular surgery specialist telehealth visit 
provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you had an 
appointment that was cancelled and then received a call from the provider. You also say that you did not know 
it would be billed as an office visit and should not have to pay for it. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $45 
copayment for a specialist telehealth visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$45 copayment for a specialist telehealth visit. A specialist telehealth visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 a vascular surgery specialist telehealth visit provided on January 19, 2022.