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

 
We decided that the Plan does not have to pre-approve dental services with an out of network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to see a holistic dentist 
because you are worried about mercury and amalgam fillings. The Plan denied your request. The Plan says 
dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services with an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out of network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you've been going to this dentist for a long 
time and would like to continue. The Plan denied your request. The Plan says dental services from an out-of-
network provider 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. 
 
You are requesting 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 pre-approve dental 
services with an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown porcelain/ceramic (D2740), prefab. post and core 
in addition to crown (D2954) and endodontic therapy, premolar tooth (D3320). 
 
You asked the Plan to pre-approve dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered 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. 
 
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 
crown porcelain/ceramic (D2740), prefab. post and core in addition to crown (D2954) and endodontic therapy, 
premolar tooth (D3320).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that you are appealing based on medical 
necessity and say that your high low-density lipoprotein (LDL) warrants further investigation of sub-clinical 
atherosclerosis. The Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan of the heart. Our reviewer 
says that statin therapy has already been strongly recommended.  You are clinically asymptomatic, and 
Medicare does not allow for screening coronary calcium scoring in an asymptomatic patient. Due to rising 
cholesterol level statin therapy has already been recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on December 20, 
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 this service is not a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal 
adjustment (D9951) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), bitewings - four radiographic images (D0274) and panoramic radiographic image (D0330) provided 
on November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to switch providers due to issues; 
therefore, the provider who performed these services should not go without being paid. 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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic 
image (D0330) but is limited to one procedure every three years. Bitewings - four radiographic images (D0274) 
is also covered but is limited to one procedure per plan year. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) on date of 
service February 16, 2021. You also received covered bitewings - four radiographic images (D0274) on date of 
service May 12, 2022. Therefore, these benefits have been exhausted as of February 16, 2021, and May 12, 
2022. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or 
established patient (D0150), bitewings - four radiographic images (D0274) and panoramic radiographic image 
(D0330) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of complications (D9930) for tooth #3 and #32 
provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were needed after surgery, and it 
should be covered. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the treatment of complications is 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. 
 
  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 
treatment of complications (D9930) for tooth #3 and #32 provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP equipment provided from 
September 2, 2022, to January 2, 2023. 
 
You asked the Plan to waive the coinsurance for the CPAP equipment. You say that Medicaid use to pay for 
this equipment but is no longer doing so. The Plan denied your request. The Plan says this cost sharing was 
charged 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 20% 
coinsurance for durable medical equipment and related supplies.  You have been asked to pay $16.60, which is 20% coinsurance of the allowed amount for the CPAP device 
from September 2, 2022, to January 3, 2023 ($83 allowed amount x 20% coinsurance = $16.60). You have also 
been asked to pay $5.48, which is 20% coinsurance of the allowed amount for the CPAP humidifier from 
September 2, 2022, to January 2, 2023 ($27.40 allowed amount x 20% coinsurance = $5.48). You have been 
asked to pay a total of $22.08 every month for the CPAP equipment ($16.60 coinsurance + $5.48 coinsurance = 
$22.08). These items/services fall within the durable medical equipment and related 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 coinsurance for the CPAP equipment provided from September 2, 2022, to 
January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that the item is an insert and does not fall under 
orthopedics, so it was coded wrong. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on November 16, 2022. 
 
You asked the Plan to pay for 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 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 February 17, 2022 and 
June 22, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
November 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture treatments (97810, 97811) provided on September 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the enrollee has already exhausted the 
allowable benefit for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan contract states that up to 20 acupuncture visits are 
provided every year for the treatment of chronic low back pain. The Plan has stated that the enrollee has 
exhausted the allowable benefit for these services. However, the Plan has not provided substantiative evidence 
that demonstrates 20 acupuncture visits were provided to enrollee for the 2022 calendar year. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay 
for the acupuncture treatments (97810, 97811) provided on September 6, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not call the ambulance, your nephew did. You also say that you should not have to pay for a service you did not 
want or need. 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 October 27, 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 October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you never received dentures from the prior 
dentist. 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 partial upper denture was exhausted on the date of service of March 27, 2020 and 
your benefit for the partial lower denture was exhausted on the date of service of March 26, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that there has been no other claim for the calendar 
year to evaluate a problem. 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. This benefit includes the 
requested limited oral evaluation  problem focused (D0140) but is limited to one procedure per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D0140 was exhausted on date of service March 15, 2022. Therefore, we 
decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided on 
November 21, 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 September 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance personnel examined the enrollee. You also say that they determined that no injury warranted 
transportation to the hospital. 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 September 29, 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 September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not use all of the $1000 in your dental 
benefit, and your provider says you needed this service to hold replacement teeth. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental 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. 
 
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 bone 
replacement graft for ridge preservation (D7953) provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified fixed prosthodontic procedure, by report 
(D6999) provided on July 6, 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 this service is not a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
fixed prosthodontic procedure, by report (D6999) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive series of x-rays, panoramic x-ray image, 
and four units of 2D oral/facial photographic image provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that these dental codes are covered under your 
contract with the Plan. The Plan denied your request. The Plan says these services are not covered by the Plan's 
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 the 
comprehensive series of x-rays, panoramic x-ray image, and four units of 2D oral/facial photographic image 
provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #14 provided on 
November 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was necessary because you 
had a hole in your tooth. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the core buildup is 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #14 provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on  
December 8, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene 
instructions (D1330) provided on December 8, 2022.