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

 
We decided that the Plan does not have to pay for frames (V2020), and tinted lenses (V2745) provided on June 
10, 2022. 
 
  You asked the Plan to pay for frames (V2020), and tinted lenses (V2745). You say that in 2022, your eyes 
changed enough that you needed a new prescription. The Plan denied your request. The Plan says you used 
your $200 allowance on eye hardware purchased on February 17, 2021, which was only one year and 4 months 
before this new purchase. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 total reimbursement for eyeglasses and/or contact lenses combined every two 
years. 
 
We looked at the file and the Plan's rules. The Plan rules say that the total reimbursement for eyeglasses and/or 
contact lenses combined is limited to $200 every two years. The record shows this benefit was exhausted on 
February 17, 2021. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), 
and tinted lenses (V2745) have not been met. Therefore, we decided that the Plan does not have to pay for 
frames (V2020), and tinted lenses (V2745) provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic 
radiographic images (D0330), and bitewings (D0272) provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told there was a limit on the 
dental services and switching to a new dentist you would have to redo the dental services again. The Plan 
denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on the date of service of March 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
panoramic radiographic images (D0330), and bitewings (D0272) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and a bitewing (D0270) 
provided on September 13, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation (D0150) and a bitewing (D0270). You say that 
you were unaware the examination would be covered once every three years. The Plan denied your request. 
The Plan says that a comprehensive oral evaluation (D0150) was denied as this exceeds the maximum allowed 
per period. The Plan also says that the bitewing (D0270) was denied as service does not meet benefit criteria. 
 
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. The Plan failed to submit the 2022 Evidence of Coverage. Without the Evidence 
of Coverage, we are unable to determine if the services were denied correctly. Therefore, we decided that the 
Plan has to pay for a comprehensive oral evaluation (D0150) and a bitewing (D0270) provided on September 
13, 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 for a limited oral evaluation (D0140), intraoral radiographic 
image (D0220), and a cleaning (D1110) provided by an out-of-network provider on October 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services and 
a cleaning was paid for previously. The Plan denied your request. The Plan says the cleaning was received 
from an out-of-network provider and are not covered by your supplemental benefits. Also, the denial of 
payment for the limited oral evaluation and intraoral radiographic image is correct, because they 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. 
 
  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 cleaning is not covered under this benefit when 
received from an out-of-network provider. The limited oral evaluation and intraoral radiographic image are not 
covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), intraoral radiographic image (D0220), and a cleaning (D1110) provided by an out-of-
network provider on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that the enrollee's preference is to come to 
our office over any in-network provider. The Plan denied your request. The Plan says the service can be 
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 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 
specialist office visit 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 pre-approve dental services (D2740, D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve 
dental services (D2740, D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the bitewings 
(D0270) provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental visit was an emergency and you have 
not utilized any covered procedures for the year. The Plan denied your request. The Plan says your benefit for 
the requested items or services 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 limited oral evaluation was exhausted on the date of service of January 26, 2022, 
and your benefit for the bitewings was exhausted on the date of service of September 23, 2022. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the bitewings (D0270) 
provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services were medically neccesary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
November 28, 2022. 
 
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 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 panoramic radiographic image (D0330) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. The Plan denied your request. The Plan says based on 
the information submitted, there is no documentation that you meet all three criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the SSBCI benefits have been met. 
Medical records were not provided with this case. The record shows that the Plan made multiple attempts to 
obtain the information, but it was not received. Without medical records, we are unable to determine if the 
criteria for coverage for the SSBCI benefits have been met. Therefore, we decided that the Plan does not have 
to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on October 5, 2022. 
 
You asked the Plan to pay for full mouth debridement to enable a comprehensive oral evaluation and diagnosis 
on a subsequent visit (D4355). You say that the provider advised you that your insurance would provide 
payment for the service. 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 full 
mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) 
provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a Dexcom G6 continuous glucose monitor would help 
the enrollee. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is needed. The Plan denied your 
request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on October 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the visit in October could be coded 
as D0120 for periodic exam as you are allowed two per year. 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 August 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on October 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
suffering from delirium due to an infection and didnt make rational decisions. You also say that you are asking 
for reconsideration of the denial due to your mental state. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
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 July 25, 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 provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, premolar tooth (D3320), and 
prefabricated post and core in addition to crown (D2954) provided on April 4, 2022. 
 
You asked the Plan to pay for the endodontic therapy, premolar tooth (D3320), and prefabricated post and core 
in addition to crown (D2954). You say that the service was necessary to prepare for your new dental crown. 
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 
endodontic therapy, premolar tooth (D3320), and prefabricated post and core in addition to crown (D2954) 
provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had a terrible tooth ache, and it was an 
emergency you see the dentist. 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 the date of service of November 24, 
2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist could not perform the molar 
extraction without an evaluation. 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 July 19, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal (D2750) 
provided on October 17, 2022. 
 
You asked the Plan to pay for the crown - porcelain fused to high noble metal (D2750). You say that you are 
not asking for payment to the dentist but are asking for reimbursement for some of the dental expenses. You 
also say that you do not understand why this particular time your dentist not being in-network is a problem. 
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 a crown - 
porcelain fused to high noble metal (D2750) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355), and panoramic 
radiographic imaging (D0330), provided on October 12, 2022, to October 20, 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 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 July 28, 2021. Therefore, 
we decided that the Plan does not have to pay for a full mouth debridement (D4355), and panoramic 
radiographic imaging (D0330), provided on October 12, 2022, to October 20, 2022.