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

 
We decided that the Plan does not have to waive the cost share for core build up on tooth #11 (D2950), retainer 
crowns on tooth #11 and 14 (D6740), and pontics on tooth #12 and 13 (D6245) provided on May 19, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you disagree with the 
processing of this claim. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
The Plan also says that your annual dental benefit has been met. 
 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 this benefit includes 
coverage up to $1,000 for covered routine dental services. The contract also says that the enrollee must pay  
50% coinsurance for retainer crowns and core build up. 
 
You have been asked to pay 50% coinsurance for core build up (D2950) on tooth #11 and a retainer crown 
(D6740) on tooth #11. 
 
Code Allowed Amount Coinsurance 
D2950 $258 $129 
D6740 $1,131 $565.50 
 
The record shows your annual dental benefit was met during the processing of this claim. You are responsible 
to any amount over the benefit limit. You have been asked to pay for a retainer crown on tooth #14 (D6740) 
and pontics on tooth #12 and 13 (D6245). These items/services fall within the dental service 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 cost share for core build up on tooth #11 (D2950), retainer crowns on tooth 
#11 and 14 (D6740), and pontics on tooth #12 and 13 (D6245) provided on May 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 26, 2021, to 
November 5, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claims should be reprocessed and 
paid. The Plan denied your request. The Plan says an exception request was not submitted to waive the 5-day 
requirement for filing the RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAPs were not 
submitted within 5 days of the from the start of care dates, April 25, 2021, September 20, 2021, and October 
26, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
April 26, 2021, to November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the extraction of tooth #5 and 6 (D7140) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that your benefit 
for the requested item or service has already 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the extraction of tooth #5 and 6 (D7140) provided 
on July 7, 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 more for a limited oral evaluation (D0140), periapical 
radiographic imaging (D0220), a core build-up (D2950), a pontic (D6245), and a retainer crown (D6750), 
provided by an out-of-network provider on June 15, 2022, to June 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this provider was able to fit her in for an 
appointment with the urgency you wanted. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation (D0140), periapical 
radiographic imaging (D0220), a core build-up (D2950), a pontic (D6245), and a retainer crown (D6750), 
provided by an out-of-network provider on June 15, 2022, to June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heel stabilizer (L3170) provided on April 12, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare for the enrollee's condition.  
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although a heel stabilizer may be appropriate for her, neither Medicare nor the Plan provides coverage of this 
item for the enrollee's condition. Additionally, the rules say that with the exception of the situations described 
above, orthopedic footwear billed using code L3170 will be denied as noncovered. Therefore, we decided that 
the Plan does not have to pay for the heel stabilizer (L3170) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341), the localized delivery of antimicrobial agents (D4381), and the drugs or medicaments 
dispensed in the office for home use (D9630) provided on June 9, 2022. 
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the items/services provided are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for the periodontal scaling and root planing-four or more teeth per quadrant (D4341), the localized delivery 
of antimicrobial agents (D4381), and the drugs or medicaments dispensed in the office for home use (D9630) 
provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were recommended to this dentist by your 
in-network dentist. 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 limited oral evaluation (D0140) provided by an out-of-network provider on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation  full mouth, after oral evaluation (D4346) provided on May 18, 2022. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation  
full mouth, after oral evaluation (D4346). You say that you thought you were receiving a regular cleaning and 
that it would be covered. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in 
presence of generalized moderate or severe gingival inflammation  full mouth, after oral evaluation (D4346) 
provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) 
provided on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought all the services your provider 
requested were covered. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT capture and interpretation (D0364) provided on August 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) 
provided on June 24, 2022. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that the enrollee required 
an ambulance due to weakness, and is on oxygen for transport. You also say that other forms of transportation 
would have been contraindicated and adverse to the enrollee's health. The Plan denied your request. The Plan 
says the denial of oxygen and oxygen supplies was appropriate given the clinical scenario and guidance 
presented.  
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on June 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided on 
April 21, 2022. 
 
You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered 
by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like 
a review. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for each Medicare-covered radiation therapy service.  
 
 
  You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan for therapy 
guide. This item/service 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 a CT scan for therapy guide 
provided on April 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 7, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on June 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services rendered to the enrollee were 
provided on an urgent basis. You also say that the enrollee needed the services to avoid wound complications 
such as deterioration, amputation, infection, and hospitalization. The Plan denied your request. The Plan says 
the claim was processed correctly. The services were rendered to the enrollee by an out-of-network provider 
without a prior authorization. In-network providers were available and capable of treating the enrollee's needs. 
Furthermore, the Plan says the record does not indicate that care would be delayed or untimely if provided by 
an in-network provider. 
 
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 wound care services provided on June 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
services (A0998) provided from June 12, 2022, to June 15, 2022. 
 
The enrollee asked the Plan to pay for the ambulance response and treatment with no transport. The enrollee 
said that they would like to have assistance with these payments. The Plan denied the enrollees request. The 
Plan says the record sent by the ambulance company indicates that the enrollee was not transported anywhere. 
 
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 June 12, 2022 to June 15, 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 services (A0998) provided from June 12, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an approved authorization. 
 
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 April 6, 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 the dental services on January 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services received were medically necessary. 
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 January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 January 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 
6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and an extraction (D7140), provided by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, and an extraction. You say that you 
believe the Plan should pay for this. The Plan denied your request. The Plan says the rendered dental services 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), intraoral imaging (D0220), and an extraction (D7140), provided by an out-of-network 
provider on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140 and D0160) and a cone beam 
(D0364) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to see your dentist 
and to have these dental procedures done. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the oral evaluation and the cone beam are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral 
evaluation (D0140 and D0160) and a cone beam (D0364) provided on June 20, 2022.