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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of any non-covered 
charges. 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 December 6, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
fluoride varnish (D1208), provided by an out-of-network provider on Jun 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered 
and paid. The Plan denied your request. The Plan says D0120 and D1110 were received from an out-of-
network provider and are not covered by your supplemental benefits. D1208 is not a covered 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 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 periodic oral evaluation (D0120), prophylaxis (D1110), fluoride varnish (D1208), provided by an 
out-of-network provider on Jun 8, 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 June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider coverage 
for a second exam. 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 June 15, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on June 15, 2022. 
 
You asked the Plan to pay for an evaluation. You say that this evaluation was medically necessary. The Plan 
denied your request. The Plan says a comprehensive periodontal evaluation (D0180) 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 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 
comprehensive periodontal evaluation (D0180) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by 
an out-of-network provider on April 27, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the enrollee only has preventative dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a crown (D2740) and a core 
build-up (D2950) provided by an out-of-network provider on April 27, 2022.
Appeal type: Practitioner Services
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 (E2311). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that you disagree with the denial. 
The Plan denied your request. The Plan says 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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. 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 (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on June 14, 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 17, 2022. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the scaling and root planning (D4342) provided on 
June 23, 2022, and July 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you should have never been charged for 
the covered dental services. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount. Also, the enrollee paid the provider directly and they were 
informed they would have to request reimbursement with the provider directly. 
 
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 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 the scaling and root planning (D4342) provided on June 23, 2022, and 
July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 the dental services on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the entire cost 
of services on May 31, 2022. 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 Plan paid 
$131 for services on March 09, 2022, and $1,672 for services on May 31, 2022, which is the annual maximum 
of $2,500. The record shows your benefit for the requested item or service was exhausted on date of service 
May 31, 2022. Therefore, we decided that the Plan does not have to pay the remainder of dental services 
provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
January 25, 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 periodontal scaling and root planing (D4341) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride varnish (D1206) provided on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this visit was the first time that you received 
fluoride. 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. 
 
The medical record shows you received fluoride varnish on January 25, 2022, and March 30, 2022. 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 25, 2022, and March 30, 
2022. Therefore, we decided that the Plan does not have to pay for fluoride varnish (D1206) provided on June 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210), 2D oral/facial imaging (D0350), adjunctive pre-diagnostic test (D0431) and immediate mandibular 
denture (D5140) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that your lower denture should be covered. The Plan 
denied your request. The Plan says these services are either not a covered benefit under your dental plan or the 
benefit has 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, 2D oral/facial imaging (D0350) and 
adjunctive pre-diagnostic test (D0431) are not among those covered under this benefit. Additionally, the record 
shows your benefit for the comprehensive oral evaluation (D0150), intraoral x-rays (D0210) was exhausted on 
date of service August 3, 2020. The benefit for immediate mandibular denture (D5140) was exhausted on date 
of service September 10, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150), intraoral x-rays (D0210), 2D oral/facial imaging (D0350), adjunctive pre-diagnostic 
test (D0431) and immediate mandibular denture (D5140) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral exam (D0140), an x-ray (D0220), a crown 
(D2750), a core build-up (D2950), and a pulp cap (D3120), provided by an out-of-network provider on July 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 exam (D0140), an x-ray (D0220), a crown (D2750), a core build-up (D2950), and a 
pulp cap (D3120), provided by an out-of-network provider on July 7, 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-ray 
(D0220), prefabricated post and core in addition to a crown (D2954) for tooth # 31, and crown (D2750) for 
tooth # 31 provided on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were originally quoted $537 from the 
provider as a hardship out-of-pocket payment. You also say that you received a bill for $434 that you were not 
expecting. The Plan denied your request. The Plan says your benefits for these dental services 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 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 benefits for the limited oral evaluation and periapical x-ray were exhausted on date of service April 
11, 2022. The record shows your benefits for the crown procedures for tooth # 31 were exhausted on date of 
service January 22, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), periapical x-ray (D0220), prefabricated post and core in addition to a crown (D2954) for 
tooth # 31, and crown (D2750) for tooth # 31 provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for prophylaxis cleaning (D1110) and a filling 
(D2393) for tooth #31 provided on October 12, 2021, and December 16, 2021. 
 
You asked the Plan to reimburse payment for the dental services. You say that the dental services should be 
covered, and you would like to be reimbursed. The Plan denied your request. The Plan says your benefit for the 
prophylaxis cleaning has already been exhausted. Also, the benefit for the filling was paid at the least costly 
method of treatment; therefore, both claims were processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan processed the filling at 
the least costly method of a silver filling. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the prophylaxis cleaning was exhausted on date of service July 7, 2021. The record also 
shows the Plan paid their share of the filling under code D2160, which is a silver filling. You have been asked to 
pay $137.56 for the silver filling for tooth #31. This means 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 reimburse payment for prophylaxis 
cleaning (D1110) and a filling (D2393) for tooth #31 provided on October 12, 2021, and December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided on 
June 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February 24, 
2022, through June 10, 2022. The Plan has covered 100 days of SNF care.  
 Although the enrollee may still have needed skilled care, the Plan is not required to pay for more than 100 days 
of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the 
enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, 
we decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided on 
June 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7120) and the placement of intra-
socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided by an out-of-network 
provider June 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should be paying 
more. 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 an extraction (D7120) and the placement of 
intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided by an out-of-
network provider on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel (80050) provided April 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that review of the medical records confirms that 
the claim is coded correctly. Please process this claim as the provider needs to get payment for this rendered 
service. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for general health panel 
(80050) provided April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and related electronic 
connections (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the expandable controller and related components. You say that it is felt that 
the requested items should be approved. The Plan denied your request. The Plan says on appeal, the wheelchair 
and other components have been approved; however, the medical necessity of the expandable controller is not 
documented. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and related 
components. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found an expandable controller is necessary when the member requires alternative controls to standard controls or when it is necessary to control multiple power drives from a single 
source. The enrollee has adequate upper body strength to use standard control and does not require an 
expandable controller or the associated accessories electronic support.  
 
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 expandable controller and related components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller (E2377) and related electronic 
connections (E2311) and harness (E2313).