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

 
We decided that the Plan does not have to pay for a consultation for a diagnostic service provided by dentist or 
physician other than the requesting dentist or physician (D9310) and drugs or medicaments dispensed in the 
office for home use (D9630) provided on October 11, 2021. 
 
You asked the Plan to pay for a consultation for a diagnostic service and drugs or medicaments dispensed. You 
say that you would not have been able to wear your dentures without the treatments and extractions. You are 
requesting reconsideration as you have a limited income and are retired. The Plan denied your request. The 
Plan says the requested services are not covered under your Plan under any normal circumstances. 
 
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 a 
consultation for a diagnostic service provided by dentist or physician other than the requesting dentist or 
physician (D9310) and drugs or medicaments dispensed in the office for home use (D9630) provided on 
October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
November 21, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on 
November 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extractions (D7140) and therapeutic parenteral 
drugs (D9610) provided on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was more like a surgery than a basic dental 
procedure, and you feel these services should be covered by your medical benefit. The Plan denied your 
request. The Plan says these services are not covered by your medical benefit or your dental 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. 
 
The services at issue involve the care, treatment, filling, removal or replacement of teeth or structures directly 
supporting the teeth. Therefore, these services are dental in nature and are excluded from coverage under Medicare and your medical benefit. Although 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 extractions (D7140) and therapeutic parenteral drugs (D9610) provided 
on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 14, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on 
September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for twenty-five (25) tooth extractions 
(D7210), four (4) alveoloplasty in conjunction with extractions (D7310) and inhalation of nitrous oxide 
(D9230) provided on July 28, 2021. 
 
You asked the Plan to pay an additional amount for tooth extractions, alveoloplasty in conjunction with 
extractions and inhalation of nitrous oxide. You say that you have no teeth and are having a hard time eating. 
You thought the entire procedure and teeth extractions, including dentures, were all covered by your Plan. You 
also say if you had known you would be unable to get dentures, you would not have started the process for 
dentures. The Plan denied your request. The Plan says you have reached your annual dental maximum with 
your 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. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of tooth extractions, alveoloplasty in conjunction with extractions and inhalation of nitrous oxide have not been met. Specifically, you have reached your annual dental maximum of $2,000 offered with your Plan per calendar year. You are responsible for the remaining balance. Therefore, we decided that the Plan does not have to pay an additional amount for twenty-five (25) tooth extractions (D7210), four (4) alveoloplasty in 
conjunction with extractions (D7310) and inhalation of nitrous oxide (D9230) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 28, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the charge should be 
included with your ER visit. 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 $60 
copayment for urgently needed care.  
 
You have been asked to pay a $60 copayment for the urgent care visit. The file shows that this was a separate 
visit from your ER 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 waive the copayment for an urgent care visit provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services (99212, A4556, 97110, 
and G0283) provided from August 2, 2021, to September 13, 2021. 
 
You asked the Plan to pay for codes 99212, A4556, 97110, and G0283. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says codes 99212, A4556, 97110, 
and G0283 are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue, codes 99212, A4556, 97110, and G0283 are not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered 
chiropractic services (99212, A4556, 97110, and G0283) provided from August 2, 2021, to September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the surgical extraction (D7210) provided on November 3, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that this service was necessary and was removed 
by an oral surgeon as you did not feel comfortable having this service performed by a general dentist. The 
procedure was quick and should not be considered surgery. The Plan denied your request. The Plan says that 
documentation supports that this procedure was performed as billed. This service is not covered by your dental 
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. Medicare rules also 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. 
 
We looked at the file and the Plan's rules. The Plan argues that the surgical extraction should be denied as this 
service is not covered by your dental benefit. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request. Specifically, the Plan did not 
submit the full and complete 2021 Evidence of Coverage for review. The Plan submitted two pages which do 
not appear to cover the full dental benefit package information and do not include the page the Plan cites in 
their denial letter. Without this information, the Plans denial of this service is not supported. In addition, the 
Plan sent several pages of the 2022 Evidence of Coverage, which does not apply to the services at issue but 
does show that surgical extractions are covered once per tooth. We cannot verify if this is a change in coverage 
that occurred between these years. The Plan has not provided sufficient information to show that this service is 
not covered by your Plan or that any rules for coverage of this service have not been met. Based on this 
information, we decided that the Plan's rules for coverage of the surgical extraction have been met. Therefore, 
we decided that the Plan has to pay for the surgical extraction (D7210) provided on November 3, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 29, 
2021, and October 5, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you had chosen to opt-out of Medicare 
because Original Medicare does not offer dental benefits. If you had known that this decision would be 
affecting your patients and payments, you would have reconsidered this choice. The Plan denied your request. 
The Plan says the provider in this case does not participate in Original Medicare. The Plan requires that 
supplemental dental services be performed by providers who participate in Medicare in order to be eligible for 
coverage. 
 
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 supplemental dental services when they are performed by a licensed dental provider who has not opted out of Original 
Medicare.  
 
We looked at the file and the Plan's rules. The provider in this case does not participate in Original Medicare. 
Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have not 
been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on June 29, 2021, and October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on November 22, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that when you called to make the 
appointment for this service, they did not tell you that there would be a copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 
copayment for x-rays and ultrasounds.  
 
You have been asked to pay a $20 copayment for the ultrasound. 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 ultrasound you had on November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement provided on June 28, 2021. 
 
You asked the Plan to waive the copayment for debridement. You say that you paid the $25 copayment and 
disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received debridement at an outpatient hospital facility on June 28, 2021. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.  
 
You have been asked to pay a $295 copayment for debridement. Debridement falls within the outpatient 
surgery and other medical 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 copayment for debridement provided on June 
28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT image capture with limited field of view 
(D0380), an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431), a pulp 
vitality test (D0460) and a consultation for a diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310) provided on October 26, 2021. 
 
You asked the Plan to pay for a cone beam CT image capture, an adjunctive pre-diagnostic test, a pulp vitality 
test and a consultation for a diagnostic service. You say that you disagree with the denial of this claim as one of 
the tests were to check for cancer and the other test was done in response to some pain you were having in your 
jaw. You are struggling with some health issues and the pain in the jaw has had some impact on your health. 
The Plan denied your request. The Plan says the requested services are not covered under your Plan under any 
normal circumstances. 
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 a cone 
beam CT image capture with limited field of view (D0380), an adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities (D0431), a pulp vitality test (D0460) and a consultation for a diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) provided on 
October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and therapeutic 
parenteral drugs, two or more administrations, different medications (D9612) October 8, 2021. 
 
You asked the Plan to pay for the panoramic x-ray and therapeutic parenteral drugs. You say that you would 
like these services covered. The Plan denied your request. The Plan says you have exceeded the frequency limit 
for the panoramic x-ray and the therapeutic parenteral drugs are not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the panoramic 
x-ray once every five years. 
We looked at the file and Medicare rules. The Plan provided documentation showing that full mouth x0rays 
were previously covered on December 1, 2020. Based on this information, we decided that the Plan's frequency 
limit for coverage of the panoramic x-ray has been exceeded. Though the Plan offers dental benefits in excess 
of Medicare coverage, therapeutic parenteral drugs are not among those covered services. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and therapeutic 
parenteral drugs, two or more administrations, different medications (D9612) October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/anesthesia (D9223) provided on October 1, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that these services are medically necessary for the 
enrollee to have any dental work done. The Plan denied your request. The Plan says this service is not covered 
by the enrollee's dental benefit. In addition, this service cannot be covered by Original Medicare as it was 
provided in conjunction with non-Medicare covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep 
sedation/anesthesia (D9223) provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-autogenous connective tissue graft (including recipient 
site and donor material) first tooth, implant, or edentulous tooth position in graft (D4275) provided on October 7, 2021. 
You asked the Plan to pay for the non-autogenous connective tissue graft. You say that you were not made 
aware that you were not allowed to see an opt out provider. The Plan denied your request. The Plan says dental 
services are not covered when rendered by providers who have opted out of Medicare. 
 
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. The Plan covers the non-
autogenous connective tissue graft when you see any licensed dental provider who accepts Medicare patients in 
the United States and has not opted out of Original Medicare.   
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the non-autogenous connective tissue graft have not been met. 
Therefore, we decided that the Plan does not have to pay for non-autogenous connective tissue graft (including 
recipient site and donor material) first tooth, implant, or edentulous tooth position in graft (D4275) provided on 
October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture with flexible base (D5226) provided 
on October 25, 2021 by an out of network provider. 
 
You asked the Plan to pay for the dental service. You say that you received this providers information from a 
plan representative. You also say that you were advised they were in network. The Plan denied your request. 
The Plan says dental 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, the dental items and services received 
out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the lower partial denture with flexible base (D5226) provided on October 25, 2021 by an out of 
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) and oral exam 
(D0120) provided from May 17, 2021, to July 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not realize that your opt out status 
would affect the enrollee's payments. You also say that an exception should be made until you are able to opt 
back in with Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of 
Medicare. The Plan also says that dental services performed by a provider that has opted out of Medicare are 
not payable. 
 
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 a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the scaling and root planing (D4341 x 2) and oral exam (D0120) provided 
from May 17, 2021, to July 21, 2021.