Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for blood collection services provided on April 
14, 2021, and August 11, 2021. 
 
You asked the Plan to waive the deductible for the blood collection. You say that the services should be 
covered as they are medically necessary and order by your doctor. The Plan denied your request. The Plan says 
the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 
deductible which applies to the blood collection. Please note that this deductible amount must be met before the 
Plan will pay their share for services received. This cost sharing is a contractual obligation that had not been 
met at the time the blood collection was received on April 14, 2021, and August 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for blood collection services provided on April 14, 
2021, and August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on September 2, 2021. 
 
You asked the Plan to pay for the dental service. You say that the temporary partial that you received the year 
before was not servicing your needs. You also say that the permanent partial is healthier and meets your needs. 
The Plan denied your request. The Plan says 1 partial upper denture is covered every 5 plan years. 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 partial upper denture is covered 
once every 5 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
partial upper denture that you received on January 7, 2020. Therefore, we decided that the Plan does not have 
to pay for the partial upper denture (D5213) provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on November 2, 2021. 
 
You asked the Plan to pay for the limited exam. You say that this service was necessary. The Plan denied your 
request. The Plan says you had a previous limited oral exam in July 2021, which was covered by the Plan at 
that time. This service may only be covered once per plan year. Therefore, you have exceeded the limitations of 
your benefit, and this service is denied. 
 
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 Plan can cover one 
limited exam to evaluate a problem (D0140) per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the exam is requested in a frequency 
that exceeds what is covered under this benefit. Documentation shows that you had a previous limited exam in 
2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the limited 
oral exam (D0140) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 31, 2021. 
You asked the Plan to pay for the dental service. You say that you did not realize that your opt out status would 
affect the enrollee's payments. You also say that an exception should be made until you are able to opt back in 
with Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of 
Medicare. The Plan also says that dental services performed by a provider that has opted out of Medicare are 
not payable. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy for the 
enrollee. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee has seen improvement consistent with 
your plan. The Plan denied your request. The Plan says the requested provider is out-of-network. 
 
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 
an out-of-network referral for physical therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided October 29, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that you had employer coverage prior to your 
Medicare coverage and consider your coverage to have been continuous. The Plan denied your request. The 
Plan says your tooth was extracted prior to your effective date with this plan. You have not been continuously 
covered for more than 24 months with this plan and therefore the implant is excluded from coverage. 
 
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. 
 
We looked at the file and Medicare rules. In this case your tooth was extracted in November 2019. You became 
effective with this plan on April 1, 2020. 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 because your tooth 
was extracted prior to your effective date with the Plan. Therefore, we decided that the Plan does not have to 
pay for the surgical placement of implant body: endosteal implant (D6010) provided October 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the foot and ankle x-ray you received on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for the x-ray 
. You say that this was part of the wellness exam from an ankle injury you had in 2015 that did not heal 
properly. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for x-rays.  
 You have been asked to pay a $30 copayment for the x-ray. Your contract says that if you receive diagnostic 
services (such as an x-ray) during an annual exam, separate cost sharing applies for that. 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 foot and ankle x-ray you received on November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure and venography rendered on June 15, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 36005 and 75822 are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 
 
 
 
 The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records show that the diagnostic angiography with injection is included in the 
approved procedures. Based on this information, we decided that Medicare rules for coverage of services billed 
with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the 
injection procedure and venography rendered on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oroantral fistula closure (D7260) provided on May 7, 2021. 
 
You asked the Plan to pay for the oroantral fistula closure. You say that you cannot afford to pay this bill. The 
Plan denied your request. The Plan says the oroantral fistula closure 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 oroantral fistula closure is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
oroantral fistula closure (D7260) provided on May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the electrocardiogram (ECG) and the non-
invasive vascular study you received on July 21, 2021. 
 
You asked the Plan to waive the copayments for the ECG and the non-invasive vascular study. You say that 
you do not think it is fair that you have to pay this amount. The Plan denied your request. The Plan says you 
were charged these copayments correctly.  The Plan says that because the allowed amounts for the ECG 
(14.27) and the non-invasive vascular study ($81.39) are less than the applicable copayments for each service, 
you are responsible for the full allowed amount. 
 
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 $20 
copayment for non-radiological diagnostic services and a $100 copayment for radiological diagnostic services.   
You have been asked to pay a $20 copayment for the ECG and a $110 copayment for the non-invasive vascular 
study (up to the allowed amounts listed above.) The ECG is a non-radiological diagnostic service, and the non-
invasive vascular study is a radiological diagnostic service. This means that you have been asked to pay the 
correct amounts 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 electrocardiogram (ECG) and the non-invasive vascular study you received on July 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the primary care office visit you had on 
August 27, 2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that because you were diagnosed with 
COVID-19 during this visit, your cost sharing should be waived. The Plan denied your request. The Plan says 
no cost sharing waivers were in effect at the time of this service.  As of January 1, 2021, cost sharing applies to 
these services, regardless of whether or not they are related to COVID-19. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible which applies to physician office visits.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to physician office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on August 27, 2021. There was no cost sharing waiver program in effect at the 
time of this service related to COVID-19. Therefore, we decided that the Plan does not have to waive the 
deductible for the primary care office visit you had on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
re-cement or re-bond inlay, onlay, veneer or partial coverage restoration (D2910), and limited oral evaluation - 
problem focused (D0140) provided November 2, 2021. 
 
You asked the Plan to pay for the periapical x-ray, re-cement or re-bond inlay, onlay, veneer or partial coverage 
restoration, and problem focused exam. You say that you would like these services covered. The Plan denied 
your request. The Plan says these services are not covered under your 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 the intraoral - periapical first radiographic image (D0220), re-cement or re-bond inlay, onlay, veneer or partial 
coverage restoration (D2910), and limited oral evaluation - problem focused (D0140) provided November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 26, 2021. 
 
You asked the Plan to pay for the dental service. You say that your x-rays have always been covered in the 
past. The Plan denied your request. The Plan says complete series 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 complete series x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete 
series x-ray (D0210) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), x-rays (D0220, D0230) and 
cleaning (D1110) provided on May 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were behind on payments and lost your 
optional benefits but were able to re-enroll within a month of losing them. You say you were told by customer 
service that you could enjoy your benefits within two days of your payment/re-enrollment and made an 
appointment for later that month based on this information. The Plan denied your request. The Plan says your 
supplemental dental coverage ended on April 30, 2021, and you did not have dental benefits on the date these 
services were provided. If you enroll in Optional Supplemental Benefits (OSBs) during the plan year, your 
coverage would begin on the first day of the month after the Plan receives your application. Medicare generally does not cover dental services. The Plan follows the same rule but offers an additional optional benefit for an extra monthly premium. 
 
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. The record shows that at the time of service, you were not enrolled in the Plan's additional 
optional dental benefits. Therefore, we decided that the Plan does not have to pay for the periodic oral exam 
(D0120), x-rays (D0220, D0230) and cleaning (D1110) provided on May 25, 2021.  
 
Your complaint about potential misinformation from the Plan regarding the start date of your re-enrollment into 
the dental OSB 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 an additional amount for the core build up (D2950) and crown 
(D2740) provided on November 3, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that your authorized 
representative contacted the plan and was informed that the services were fully covered. The Plan denied your 
request. The Plan says there is an annual maximum of $1,000 for covered dental services. The Plan also says 
that the maximum was met in the processing of this claim. 
 
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 annual maximum benefit of $1,000 
has been met. The record shows that the Plan paid $138 for services received on October 13, 2021, $686.17 for services received on October 19, 2021, and $175.83 for services received on November 3, 2021. $138 + 
$686.17 + $175.83 = $1,000. Therefore, we decided that the Plan does not have to pay an additional amount for 
the core build up (D2950) and crown (D2740) provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81291, 81230, 81408, 81479, and 
81355) provided on February 26, 2021. 
 
You asked the Plan to pay for codes 81291, 81230, 81408, 81479, and 81355. 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 laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81291, 81230, 81408, 81479, and 81355) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a retreatment of previous root canal 
therapy (D3347) provided on November 17, 2021. 
 
You asked the Plan to waive the cost-sharing for a retreatment of previous root canal therapy. You say that you 
should have been reimbursed 50% of what you paid for the procedure. The Plan denied your request. The Plan 
says rules for additional payment have not been met. 
 
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 Plan provides a maximum 
allowance of $1,250 with 50% coinsurance every year for supplemental comprehensive dental services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
additional payment for a retreatment of previous root canal therapy have not been met. The record shows that 
the Plan has paid $125 for the procedure at issue. The Plan has documented that the $125 payment exhausts 
your supplemental dental benefit for the 2021 benefit year. Charges over the maximum allowance are your 
responsibility. Therefore, we decided that the Plan does not have to waive the cost-sharing for a retreatment of 
previous root canal therapy (D3347) provided on November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Als routine disposable supplies (A0398) provided on  
May 25, 2021. 
 
You asked the Plan to pay for Als routine disposable supplies (A0398). The Plan denied your request. The Plan 
says payment for items and services, such as oxygen, is included in the fee schedule payment. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for Als 
routine disposable supplies (A0398) provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the intraoral - periapical first 
radiographic image (D0220) and crown - porcelain/ceramic (D2740) provided February 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to provide additional payment for the intraoral x-ray and crown. You say that you were not 
billed by this dentist in the past. The Plan denied your request. The Plan says the service has processed 
correctly according to your OON 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 Plan covers the intraoral x-ray with a $0 copayment and crowns with a 50% copayment after the $100 deductible is met.  
 
We looked at the file and Medicare rules. In this case the Plan covered 100% of the allowed cost for the 
intraoral x-ray. The Plan applied your $100 deductible to the crown and paid 50% of the allowed amount. The 
claims have processed correctly according to your benefits. You may be charged the difference between the 
Plans allowed amount and the total cost billed by the provider because the services were provided OON. 
Therefore, we decided that the Plan does not have to provide additional payment for the intraoral - periapical 
first radiographic image (D0220) and crown - porcelain/ceramic (D2740) provided February 4, 2021, by an 
out-of-network (OON) provider.