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

 
We decided that the Plan does not have to pay for the fillings (D2332 x 2) and core build up (D2950 x 2) 
provided on October 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that the fillings were causing your gums to bleed at 
your teeth were very short. You say that you had only used $350 of the $2,000 maximum benefit. You also say 
that it is very hard to pay this bill. The Plan denied your request. The Plan says 2 fillings are covered per 
calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says core build up is not 
listed as 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the 
frequency limit of 2 fillings per calendar year has been exceeded. The record shows that the Plan paid for 1 
filling that you received on April 14, 2021, and 1 filling you received on October 11, 2021. Additionally, core 
build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2332 x 2) and core build up (D2950 x 2) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling (D2330), provided on October 12, 2021. 
 
You asked the Plan to pre-approve a filling. You say that the service was medically necessary. The Plan denied 
your request. The Plan says this is 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 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. Specifically, this service is not listed in the Plan's benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pre-approve a filling 
(D2330), provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implants (D6010), surgical removal of 
implants (D6100), alveoloplasty with extractions (D7310), and therapeutic parenteral drugs (D9612) provided 
on September 23 to October 21, 2021. 
 
You asked the Plan to pay for surgical placement of implants, surgical removal of implants, alveoloplasty with 
extractions, and therapeutic parenteral drugs. You say that you were advised by a representative of the Plan that 
the procedures at issue would be covered. The Plan denied your request. The Plan says the services at issue are 
not a Plan benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 surgical placement of implants (D6010), surgical removal of implants (D6100), alveoloplasty with extractions (D7310), and therapeutic parenteral drugs (D9612) provided on September 23 to October 21, 2021.  
 
Your complaint about receiving erroneous or incomplete information about your supplemental benefits from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), periapical x-ray (D0230), 2D 
photographic image (D0350 x 2), and 3D photographic image (D0351) provided on October 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office performed all of these 
procedures without clearing things with you first. You also say that you feel these services should be covered. 
The Plan denied your request. The Plan says 2D photographic image and 3D photographic image are not listed 
as covered services. The Plan says that 1 panoramic x-ray is covered every 3 years. The Plan says that 1 
periapical x-ray is covered per calendar year. The Plan also says that these frequency limits have 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, the 2D photographic image and 3D 
photographic image are not among those covered under this benefit. Additionally, the frequency limits for the 
panoramic and periapical x-rays have been exceeded. The record shows that the Plan paid for a panoramic x-
ray that you received on March 23, 2021. The record shows that the Plan paid for a periapical x-ray that you 
received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330), periapical x-ray (D0230), 2D photographic image (D0350 x 2), and 3D photographic 
image (D0351) provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgeries provided on 
November 8, 2021, and December 8, 2021. 
 
You asked the Plan to waive the copayments for the outpatient surgeries. You say that you should only be 
charged 1 copayment for the surgeries. The Plan denied your request. The Plan says the proper copayment was 
applied for each date of service the provider billed for. 
 
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 $325 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. For both dates of service, the total copayment amount was $650 ($325 copayment amount x 2 dates of 
service). You have been asked to pay a $650 copayment for the outpatient surgeries. The outpatient surgeries falls 
within the Outpatient surgery, including 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 copayments for the outpatient surgeries 
provided on November 8, 2021, and December 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services (G0299, Q5001) provided to the 
enrollee from June 29, 2021 to June 30, 2021. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the required RAP was not submitted in a timely fashion. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP 
claim was not received until November 5, 2021. Therefore, we decided that the Plan does not have to pay for 
the home health services (G0299, Q5001) provided to the enrollee from June 29, 2021 to June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided by a participating 
provider on September 15, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that this was your only check-up this 
year. The Plan denied your request. The Plan says that the benefit limit for D0150 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. The Plan covers a 
comprehensive oral evaluation once every three years. 
 
We looked at the file and Medicare rules. Evidence was not provided to verify a comprehensive oral evaluation 
was provided within the last three years. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation have been met. Therefore, we decided that the Plan has to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on September 15, 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 root canal (D3310), prefabricated post and core in 
addition to a crown (D2954), crown (D2751), and periapical x-ray (D0220) provided from August 9, 2021, to 
September 29, 2021 by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan also says that 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental 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 root canal (D3310), prefabricated post and core in addition to a crown (D2954), crown (D2751), and 
periapical x-ray (D0220) provided from August 9, 2021, to September 29, 2021 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care physician (PCP) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PCP services. You say that you would like to keep the same PCP that 
you had prior to enrolling into the plan. The Plan denied your request. The Plan says the PCP that the enrollee 
is requesting to see is an out-of-network provider and there are several in-network providers that provide the 
same service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
primary care physician (PCP) services to be provided 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 limited oral evaluation (D0140), periapical x-ray 
(D0220), core build up (D2950), and crown (D2740) provided from November 9, 2021, to November 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out of 
network. The Plan denied your request. The Plan says the services you received are not listed as 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 services you received are not 
among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), core build up 
(D2950), and crown (D2740) provided from November 9, 2021, to November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter tea tree oil you purchased on October 13, 2021. 
 
You asked the Plan to pay for tea tree oil. You say that your doctor recommended tea tree oil for treatment of 
nail fungus.  You stated that the Plan does include anti-fungal treatment on the list of eligible expenses, but not 
the tea tree oil recommended by your doctor. The Plan denied your request. The Plan says tea tree oil is not 
covered under your supplemental "Pick your Perks" program. 
 
The Plan must follow Medicare rules. Medicare rules say that over-the-counter (OTC) items are generally not 
covered by Medicare, but Plans may cover OTC items as a supplemental benefit.  This means that the Plan's 
contract will specifically list which OTC items are coverable under this benefit.  The Plan has a list of 
Approved Over-the-Counter Items in the Pick Your Perks benefit brochure.  Tea tree oil is not listed as an approved, covered OTC item.  The Plan does not have to pay for tea tree oil, regardless of whether or not it was 
recommended by your doctor. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of tea tree oil have not been met. Therefore, we decided that the Plan does not have to pay for over-
the-counter tea tree oil you purchased on October 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the therapeutic exercises (97110) provided 
on November 8, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 therapy visit.  
  
You have been asked to pay a $35 copayment for the therapy visit provided. 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 therapeutic exercises (97110) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and outpatient services provided on July 27, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and outpatient services. You say that the enrollee is now your 
patient, and you believe the enrollee switch their primary care provider to you. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from the enrollee's 
primary care physician 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 and outpatient services provided on 
July 27, 2021, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 52 visits for Ferumoxytol infusion. 
 
You asked the Plan to pre-approve the 52 visits for Ferumoxytol infusion. You say that you would like 
reconsideration because the requested infusion is medically necessary. The Plan denied your request. The Plan 
says the requested infusion exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 the 52 visits for Ferumoxytol infusion. 
Our reviewer says that the requested 52 visits are excessive and would not be medically necessary. Given the 
provided documentation, the enrolee does not meet the guidelines for the requested service. Our physician 
reviewer found the documentation does not support that the 52 visits for Ferumoxytol would be safe and 
effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 52 visits for Ferumoxytol infusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the 52 visits for Ferumoxytol infusion.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97167) provided September 22, 2021. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97167 is not supported in the medical record. Specifically, the record shows this service 
was performed by a therapy assistant in the home health setting. There is a more appropriate CPT code to 
describe this service (G0157). Based on this information, we decided that Medicare rules for coverage of the 
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (97167) provided September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that you believe that every check you have gotten at 
the dentist office has included at at least 4 x-rays. You also say that this bill should be paid. The Plan denied 
your request. The Plan says bitewing x-rays are covered once per plan year. The Plan also says that the 
frequency limit 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 and bitewing x-rays are listed as 
covered, the frequency limit of once per plan year has been exceeded. The record shows that the Plan paid for 
bitewing x-rays that you received on March 23, 2021. Therefore, we decided that the Plan does not have to pay 
for the bitewing x-ray (D0274) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 23, 2021. 
 
You asked the Plan to pay for the panoramic x-ray. You say that the provider in this case is listed in the 2021 
and 2022 book of in network providers. You also say that these services should be covered. The Plan denied 
your request. The Plan says panoramic x-ray is not listed as 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the services should be 
covered in full as it was a screening colonoscopy. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $345 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $345 copayment for a diagnostic colonoscopy. Diagnostic colonoscopies fall 
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 diagnostic colonoscopy provided on October 22, 2021.