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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 11, 2022. 
 
You asked the Plan to pay for the dental service. You say that this is a new provider for you this year. The Plan 
denied your request. The Plan says your benefit for the comprehensive oral evaluation has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 18, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periapical x-ray. We decided that the Plan does not have to pay for 
the limited oral evaluation.  
 
You asked the Plan to pay for the dental services. You say that the enrollee's crown came off for the second 
time in five months. You say that an x-ray was done and determined the tooth was in pieces. You say that you 
feel this was an emergency. You also say that the services should be paid. The Plan denied your request. The 
Plan says your benefit for the oral exam and periapical x-ray have already been exhausted. 
 
We decided that the Plan has to pay for the periapical x-ray.  
 
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. Specifically, the file does not support that the plan has paid for a periapical x-ray 
within the last 3 years. Therefore, we decided that the Plan has to pay for the periapical x-ray.  
 
We also decided that the Plan does not have to pay for the limited oral evaluation. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service February 9, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation. 
 
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 surgical extraction (D7210) provided on March 1, 2022, 
by the out-of-network provider. 
 
You asked the Plan to pay for the dental service. You say that you had cracked your tooth. You say that it was 
extremely painful. You say that you needed to have it removed as soon as possible. You also say that it was 
done at an approved office, and it should be covered. The Plan denied your request. The Plan says the surgical 
extraction was 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 Plan's 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 surgical extraction is 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 surgical extraction (D7210) provided on March 1, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4341 x 2) provided on April 7, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says periodontal maintenance (D4341) is not covered by your 
routine dental 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 
periodontal maintenance (D4341 x 2) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 5, 2021, billed with 
codes 81230, 81240, 81241, 81249, 81291, 81408, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 5, 2021, billed with codes 81230, 81240, 81241, 81249, 81291, 81408, and 81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of continuous positive airway pressure 
(CPAP) device (E0601) to be provided by an out of network provider. 
 
You asked the Plan to pre-approve the replacement of CPAP. You say that the machine you have is more than 
20 years old and is being held together with duct tape. The pressure that you need hasn't been updated for 20 
years. You doctor says that you need a better CPAP. The Plan denied your request. The Plan says the requested 
vendor is not a Medicare approved supplier. Enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve replacement of continuous positive 
airway pressure (CPAP) device (E0601) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have problems with swelling in your feet. 
The Plan denied your request. The Plan says the shoes are not an integral part of a covered brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) 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 do not show that you suffer from diabetic foot disease or wear a leg brace. Although orthotics may 
be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. 
Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), resin-based composite 
(D2392), crown (D2740), and core buildup, including any pins when required (D2950) provided on March 1, 
2022, and March 3, 2022. 
 
You asked the Plan to pay for the panoramic x-ray, resin-based composite, crown, and core buildup. You say 
that you signed up for the dental supplement when you signed up with the Plan. You also say that you found 
out after a claim was rejected that you did not have coverage. The Plan denied your request. The Plan says 
these services are not covered. The Plan also says that you were not active in a supplemental dental plan at the 
time of service, nor did you have additional supplemental funds to cover these services. 
 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 
panoramic x-ray (D0330), resin-based composite (D2392), crown (D2740), and core buildup, including any 
pins when required (D2950) provided on March 1, 2022, and March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 additional periapical x-rays (D0220) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that your insurance would 
not cover all of the x-rays. You say that you have never had to pay out of pocket before. You also say that you 
were unaware of any bill you would have to pay out of pocket. The Plan denied your request. The Plan says 
your benefit for periapical x-rays have 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 Plan's 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 periapical x-rays were exhausted on date of service January 6, 2022. Therefore, we 
decided that the Plan does not have to pay for the 2 additional periapical x-rays (D0220) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), topical application of 
fluoride (D1208), and periodontal maintenance (D4910) provided on December 9, 2021. 
 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 the enrollees annual maximum for dental services has been 
exhausted. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract with the Plan clearly says that the enrollee has a 
$1,500 annual maximum for covered dental services. The contract says the enrollee is responsible for any 
remaining charges above the annual maximum amount. 
 
The record shows the enrollee has met the annual maximum amount and is responsible for the charges. The 
enrollee has been asked to pay a total of $204 for the dental services received on December 9, 2021. An 
evaluation, fluoride, and periodontal maintenance fall within the Dental Services benefit category. This means 
that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we 
decided that the Plan does not have to pay for a periodic oral evaluation (D0120), topical application of fluoride 
(D1208), and periodontal maintenance (D4910) provided on December 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from March 15, 2022, 
to March 31, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you thought this would be covered 
since you were there less than 60 days ago. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $188 
copayment per day 21 through 100.  
 
 You have been asked to pay $2,068 ($188 x 11 days) copayment for SNF care. SNF care falls within the 
Skilled Nursing Facility (SNF) Care 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 
SNF care provided from March 15, 2022, to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on February 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was no 
longer participating in the network. 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 Plan's 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 October 15, 2021. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-rays 
(D0220 x 2), cone beam computed tomography (CT) capture and interpretation (D0364 x 2), pulp vitality tests 
(D0460 x 2), root canal (D3310), and consultation (D9310) provided from December 15, 2021, to March 2, 
2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that there are no in network providers in your area 
that do root canals. You say that you sent in an out-of-network claim form. You say that you thought you did 
everything you needed to. You also say that you need these services to be covered. The Plan denied your 
request. The Plan says dental services received out-of-network are not covered. The Plan also says that 
authorization to see an out-of-network provider was not obtained for the dates of service in this case. 
 
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 
limited oral evaluation (D0140), periapical x-rays (D0220 x 2), cone beam computed tomography (CT) capture 
and interpretation (D0364 x 2), pulp vitality tests (D0460 x 2), root canal (D3310), and consultation (D9310) 
provided from December 15, 2021, to March 2, 2022, by the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unspecified iron 
deficiency anemia. She has not tried and failed the Plan's required drugs, Infed, Venofer, or Ferrlecit. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on May 4, 2022. 
 
You asked the Plan to pay for a guard. You say that without a guard you will lose more teeth because of your 
teeth grinding. The Plan denied your request. The Plan says an occlusal guard (D9944) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee has not had steady use of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that positive airway pressure devices are only 
covered under certain medical indications.  
 
 
 We looked at the file and Medicare rules. The records do not show that the enrollee has demonstrated 
adherence to the use of a CPAP device and related supplies. Based on this information, we decided that 
Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continuous positive airway pressure (CPAP) supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
30, 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 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 comprehensive oral evaluation (D0150) provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors, including all related electronics, 
indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says the electrical connection between the wheelchair 
controller and two motors (E2311) cannot be covered. Although two power features are requested for this 
wheelchair (tilt and elevating leg rests), there is not a medical need to control these power options through the 
joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors, including all related electronics, 
indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy services provided from 
March 30, 2022, to April 13, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you were told you would not 
owe anything, and you should not be responsible for this cost. The Plan denied your request. The Plan says 
they found that you were given incorrect information by an in-network provider and have agreed to waive some 
of these copayments; however, you were given accurate information on March 25, 2022, and are responsible 
for the contractual copayments from that date forward. 
 
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 $35 
copayment for each outpatient rehabilitation therapy visit.  
 You have been asked to pay a $35 copayment for each physical therapy visit. Physical therapy falls within the 
outpatient rehabilitation therapy 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 
physical therapy services provided from March 30, 2022, to April 13, 2022.